SFD (0301-034)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
074074 B'.`TIC �,^' �^ - in i r o.3
,,Date a�, "° Signature of Contractor~X'i
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.17044,• Business &eProfessionals
Code).
O I am exempt under Section 21, 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 p t# r.)w, FUN, Policy No. 04& r �.;i�•'/,00
i 4
(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, should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions. 1�
Date: Lr • — : f f A'" Applicant.--.
Warning: Failure to secure Workers' 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 isihereby made to the Director of Building and Safety
for a permit subjectto:'the conditions and restrictions set forth on his
application. - ' �'11/
1. Each person upon whose behalf this application -is made& each person at
whose request and for?whose benefit work is performed under or purs tv
any permit issued as a result of this applicaton agrees to,,&fshall, ind fy
& hold harmless the City of La Quinta, its officers, agents "and empl
2. Any permit issued as a result of this application becomes null and d if
work is not commenced within 180 days from date of issuance of u
permit, or, cessation of work for 180 days will subject permit to cancel a io I.
I certify that i have read this application and state that the above informa ion s
.correct. I agree to comply with all City, and State laws relating to the b 'Iding
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposesr r >
Signature (Owner/Agent) Date F'
BUILDING PERMIT PERMIT#
DATE VALUATION 10 LOT TRACT
r240,11 7. 54
JOB SITE
ADDRESS
OWNER
CONTRACTOR / DESIGNER / EN INFER
;e" O DOD 1716
7 9-295-l'M'�3.yi M.F d�oi Lt. QLWV�1,t R.
LAS, C)U1M CA .922S3
LA, QiiriN:t,'.A1 C A 92253
(760)771x1941 IU5
•' s 9r;�; /
USE OF PERMIT
SlYD - WT 54, re4A,1 V,1 i'{.r:1'2MIT T.34,tES NOT TtlCL:8 OR, 81., ►CK.'1re'•,Af,i.,S.
Pool, gLPA O ia€ �'•��,5'.�i��?��3t�CEI �Q�o'�1�A,�;1�i���'S� tr�b. i_
RPODUCT10t4 F0P,"AATJ T1;) ,Z MEWANCZ, ars SAME PLA'? 'rWE
Ci1iv"1OM COMTRUCTION, i2,049 ST?
PORCMP.ATIO /`-7isin) SP'
Z
GARAGt7 C RPORT 00 .n
A4Y.CtrI,.8.h5.Y!' MISTOP A,•Y.1.�+a THIJ MON. .
gr4.4 11 1.10
v y;v� �,t,'y r+ys•�:�tq�al,l
C9141WIT 2UC3TiON MC )01.000-4184000 $111391110
KAN Ci' Er"'.K ME 101-000.439-318 $232.34
MIRC'iiWICALFER ' 101.000-421.000 $I30.0
WXrlRICALPUP 101-t4420-000 $169.rA
YYVYBIM POP,101--000-4199-000 Mi.13
S1PRONO Mt' TXI Ai FE .• RESf13 101.1101+•• W) •000 '€2A
OitA1; CRI I, 101s000-411.000 $i�iiitl
TIOVY1, OPER, IMPACT ISL?. $44wi.OD
T 114 Pfg'Et"i C Fg,f ACES ROW µ7+)n0td0 44555.1rgc70 $1000,29
3i°f L 03a�:1�x�Y;C TtC W �21`tD PLAN CHEM.,
a o 133 PRE-PAYD.E'.0
$0.00
AN 2 2 2003 )WAL FERMU i DUE NOW
ITl(OF,"I:A QUINTA
'FINANCE DEPT.
RECEIPT
DATE
BY . 1
DA FI ALE P
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
J —
Ducts
Slab Grade
— —3
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to WrapF.A.U.
`��
Framing
Compressor
Insulation
—y -- ,
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
r —
Drywall - Int. Lath
_
Final
—
Final
BLOCKWALL APPROVALS
steel
POOLS - SPAS
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
Water Piping
_
Plumbing Final
Plumbing Top Out
_
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Z —
Encapsulation
Gas Piping
Gas Test
4, — 30
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: