RPL (0308-079)57108 Medinah
0308-079
LICENSED CONTRACTOR DECLARATION
I hereby 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
1 1 '
05121 :1 x:29 f il3Cl13t
Dale 's+' t`% „' Si nature of Contrac o
-T 9
OWNER -BUILDER DECLA
I hereby affirm under penalty of perjury thafkarn exempt from the Contractor's
License Law_for the following reason:
( ) 1; 4as 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). 11") .
() I am exempt under Section B&P..C. forethis reason
Date ir''Y °t`1" Signature of Owner --._ ..
WORKER'S COMPENSATION\DEC ARATION
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.
(V) 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 STATS FUND Policy No. 1612760-03
(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 workers' compensation p ovisions'of Section 3700 of the Labor
Code, I shall forthwith comply with,those/provisions.
D tom' +)''(.'c _Applicant _.x`17!? .il.I _•1,
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal pe P alties 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 employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws re al ting of the building
construction, and herdby authorize reb' esentatives of this City to enter upon
the above-mentioned property for inspection purposes. j
ignature (Owner/Agent] f t :_ ' "" Date { a t4i L
BUILDING PERMIT PERMIT#
DATE VALUATION .: +' ' LOT®79 TRACT .
JOB SITE
ADDRESS7 g ✓.
APN
_
OWNER
CONTRACTOR / DESIGNER / EN (NEER
CRAIG CaNLEY
TOPAAt.- N B Uxi. DF4,R
5'7.108 MWINAR
P0.13OX 10202
LA Q=A A ( CA 92253
VAL M E FRSERT CA .922.55
.(%6O)?7' 'd'729ti G1iY,257..
USE OF PERMIT
P001., MilVO .31)A
P001, SP.Ac 1q.R BP1T. ,Al.t1.i+~MS/.BAPR11MS SHALL RF TN PLACP AT
1'R.k°r•PIA01dTER.1NSPECTION, ErQ11IRMENT Z RCV)SURENOT 3TiC,i,U'DED
P001.,,. NDIOR S.PA. 23,000.00 gas
VEST.WWfi'. D COST OF co.P7m1<St',:,Z'1':on,
28,ow.E
RY
k'3r"zuu m SUMMARY
.i UR CHECK FEE 1.01.'000-439-318
000.439-315
C, 03d: ,,Y'i P.,UCTi6z4 ,,rue 101-00 e i1.30
MiiCHANICAL FEE -- P001, 1 T' -000-42-O0O., $209.
ELAC;` RIC AL, IEEE , POOL 1 d11-Ui il-cl20-t3IIi1
PLU1bI13.i J FEE - POOL : 1Ci1wGCit3 19 000 a2?.OD
P[:AUG
15.2003
CITY OF LA QUINTA
FINANCE DEPT.
+
SUB -TOTAL r1, i.=n,Nn ct, . Y fYAt,! CiTntyK
V11+ f
3.98
7 .S.9 PRE4?PTD .l i£
$0,00
RECEIPT 'DATE
BY
D F
I NSP R
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 77100
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
Water 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:
FROM :J GRAHAM
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RESIDENCE: i
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DESCRIPTION DATE DESCRIPTION DATE
ITEM NO.
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