SFD (0301-033)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 #674(r/4
y}u /{ xgLigc.. Class Exp. Date. ' /n
Date, '"— : ,� �• "��� 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.
�(J) 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 91'A'1',! N'1Mt) Policy No. 046-11158-2003
(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 provisions of -Section 3700 of the Labor
Code, I shall forthwith comply with those provisions. --
Date: Applicant—
Warning:
pplicant Warning: Failure to secure Workers' Compensation coverage is unlawful{and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is mad
whose request and for whose benefit work is performed uC r pursu p to
any permit issued as a result of this applicaton agrees to, ali iR
& hold harmless the City of La Quinta, its officers, agent pn employees'.
2. Any permit issued as a result of this application becom n II an�v`gd a� �n
work is not commenced within 180 days from date of u nce of su
permit, or cessation of work for 180 days will subject per it t cancellation.
I certify that I have read this application and state that the ab
g,ve info WE
11
correct. I agree to comply with all City, and State laws relat
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property -for inspection,purposes:.
Signature (Owner/Agent) r Date
BUILDING PERMIT PERMIT#
0301-033
DATE VALUATION �A0 LOT 4 TRACT 21945'.'3
JOB SITE
ADDRESS^'� e�lSda•rbtl: fQt°�'
APN
OWNER
CONTRACTOR/ E+NN IINEERR '
y�yyg+y�i y.Y� C}�� �w T)
T.[:.+.L.I,1..''►'YJ.°aC .J)Vn1�: T.i�.R"tYAJ,S.AV"d1,
�DESIGNER/
9
c�.�,�::�i.fgwi.S' S,+�. NEIIISS.IBIr,�I,AC�i'q
PO WX 13 1
;3AQUAWD. CA 92253
1:.A.QViNSA. CA 92253
(�t 0)1171-1941 :; 'CRx� 2SW`
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USE OF PERMIT
SYD I".L'J`T -71 Pt�.-�`l4'3,W El PERMIT UC3FtA�",�V.S`�tNOT`liC[eWs,A1J..°` °
Ya
PLAN�f�:AXJ:)!. C$fvl.00
i,?KPLAN.i:i7ECK iI'99
CU05'0M COTRJJCTION Z92'4,09 �a1?V.
1' °LIM.tiIiJ.t'!s `°�h." 'Si.'°�, �. 1!V �I'
r? q,.'n��F'?�` ,
C'?A:1 's MYCA 1iy4 1U.' 40,144 OF
•,v .,
P) .11 ' FEE Wl3 k RY
CON L+i'AUCTION RE
PLAN CHECK €EK 101-000439-318 S232.A
MECTfiMWA'lo FEE 101 wOt)t 421 e,000 i0(109
L''iAWMCAL B+Fy $16944'
PLVMiBING FE, 8 101 -000a41;)400 21751, 75
ST1?OW113 M YT1ON FF.Z • RJ STV 101-000.241-000 $34.01
0AAD1110 FS ? ."a
TJ WIEWPER IMPACT FWP $2,40&00
ART nw1i'c'70-0C10445.000
n :�1.T? YO`T..�FW :'O1d.5%`}�"i it~1'! [{ 31F �i1 �''� • '3 ��i f�k f ht:,`%
wa3,3 ; .Cl3
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2003 TWALTo- xrr.arKEN DU1 now
ay
)UINTA a
EPT. '
RECEIPT
DATE
BY
DAyE F A
INSPECTOR
g fi, r
l J1 1
/Yn�
I
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
.3
Exhaust Fans
O.K. to Wrap
Framing
_2 _
F.A.U.
Compressor
Insulation
— 7
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final � 2
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
I I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
�_ 'j g
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
/J, OF
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) 610.E
COMMENTS: