RC (0312-107)78010 Main St Ste 104
0312-107
LICENSED CONTRACTOR DECLARATION
44hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with,Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
%Z4 ,Date f /Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) I, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
( ) I, as owner of the property, am exclusively contracting with' licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
( ) I am exempt under Section B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
( ) I have and will maintain a certificate of consent to self -insure for workers'
compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
°( ) I have and will maintain workers' compensation insurance, as required by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier "'f.A:TE FU:F3P Policy No. 1440125.03
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, -and agree that if I should.become
subject to the wor &s' compensation provisions of Section 3700 of the Labor
Code, I shall rthwith comply with those provisionsZ,
,Date: !. /.4, %4ApplicantF.• /,A. A
Warning: Failure to secure Ukorkers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to;the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employee
2. Any permit issued as a result of this application becomes null and void
work is not commenced within 180 days from date of issuance of su
permit, or cessation of work for 180 days will subject permit to cancellatio
I certify that I have read this application and state that the above information
correct. I agree to comply with all City, and State laws relating to the buildin
construction, and hereby authorize representatives of this City to enter upo
the above-mentioned property for inspectionpurposes.
I,, -.Signature (Owner/Agent) jt-- %' ' Date /'
BUILDING PERMIT PERMIT#
f.L'I-1fJ'Y
DATE VALUATION LOT TRACT
JOB SITE APN
ADDRESS
OWNER CONTRACTOR/DESIGNER/EN (NEER
t
OLD 'iii ON LA QUXTA 1 t3: VtI Y HohMoo
78.080 ALU! IE s.' T. ADO 2.01 79-080 CALX -E VMADO SM, 203
LNQUI:NlA. ',CA 42253 LAQTJWTA. Ci3, 92253
('Y 0)7'11.2567 C LR 5407
USE OF PERMIT
LGA Mt7MA . PM.f 7EDET.
COMMERCIAL R'l:MOD L" (PANS A— RPFLFC T TI) 613 S.F. 'U"
.VCUPANt`'Y, TYPP-' VW<IPRJN:KC.11,, OCCITANT 140Ab 21, 2001 CB(,'
:RXI'L.ACE', PERUI'T 0309.053
V.r'iLUA T10N
21353,00 1,1111,
ER' MATED COST ill, (1101 'S'.tRU 011 2156 .00
I?R'' . VI° F;I%.'11: S'"d AUVWl
PIAN C1 ECK FEE 101.000.435-:318 $35,10
L"ONN FRuC TION T'E1: 1011-000-418-1000 $54.00
M11CI1,KRIO L FEE 101-000.421 X000 $19.50
E1"ECTRIC.AL .PEZ 101-000-4.20.000 S27.25
STRONG M011014 - COMM 100.000.241-000 x150
w3UU-` UYA3L. CONSTRITC°WN ARD P:LA9 CHFA=' $136.36
1.11;+.353 PIM -PAID IgE3 I$0100
Q T0rml f' 3'r+ 0_1:'07XS DUE .90W
0
DEC 11 2003
CITY OF LA QUINTA
FINANCE DEPT. Ir
CEIPT DATE BY DATE FINALED INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Mater Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
DEC -16-03 TUE 03:46 PM MARVIN HOMES
LA QUINTA
FETY DEPARTMENT
qm,,T/
7-7012
OV Vlx K-CT110 REQUEST LINE
7-7153
Owno, LA. QUINTA
Cont i actor_ MAIR VIN.MEMHATS- ......
Flermit
POST ON JOS IN CONSPICUOUS PLACE
INSFIF--CT011 MUST SIGN ALL APPLICABLE SPACES
18-010 MAIN STREEll S'UTTE 104
JOB ADDRESS-_....."'
CONINIFACfAl,lamonvi, (PAWS& REPLECT'rf) 613 S_F
I'M" Or; CUPANCY,TYPE VN SPRMLR, OCCUPANT
IjOAD 21, 2001 CDC REPLACES PERma 0309-053
TYPE OF INUE0110N 00t INSP.
R
LI/G PI U M C31 N G / Vvilil, f
UK, 171 FGTAICAL/ 0110UNQING
DO NOT POUR CONCH ETE UNTIL ABOVE SIGNED
flOOf- NAIL IRE -ROOF
OKAY'1'0 WRAP
I ' NATION)___
J ii -I F 1. F, CT Fl IC
G
ROUGH PLUMBiNG
ROUGH MC-(1-1ANICAL
COVER No WORK UNTIL 1ABOVE SIGNED
Kri-6011 GYP 81). V
. - - (L I - R
LAIN
EFI'(I0 AtIANI)ONMEN,r
8r'WF_R CONNECTION
..... .....
SrPTIG / GREASEINTFRCEPTOR
MM.30NRY INSPECTIONS
`001./6'X/W_ Tn RE INSPECTIONS
ONS
PHE JNFl E I *SF-TOACKS
U/c, FLUMBING4
IJ/GEI.FCIHICAL
FIiC:I!1
VINAL INSPECTIONS
7-
. .........
K, _lC,W0R1(50F.F)AF0'MEN r
rINA L JOB C( M PL ET L: D
ABOVE APPROVALS DO NOT INCLUDE RIGHT TO
TURN ON LIT'll-ITIES OR OCCUPY BUILDING