SFD (0301-018)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
674074 7/;41/03
at- Signature of Contrac or,
OWNER -BUILDER DECLARATION
;1 hereby: affirm under penalty of perjury that I am exempt from the Contractors
,-Litens'eLaw ' for -the following reason:
4,
owner of the
tt.'� ,
property, or my employees with wages as their sole
co I m . pen I satiq'n, will do the work, and the structure is not intended or offered for
sale (Sec 7044; Business & Professionals Code).
I,- as.bw'hei of.the property, am exclusively, contracting with licensed
contractors -to c 11 nstruct.the project (Sec. 7044, Business & Professionals
Code).
Y I am e e Tx i"ipt under Section B&P.C. for this reason
Date,,' ..,Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby ,affir . m under penalty of perjury one of the following declarationsi.
O I have and will maintain alcertificate of consent to self -insure for workers'
&brnpensation; as provided for by Section 3700 of the Lab6r Code, for -the
performance of the work for which this permit is issued.
(.)l have and will maintain workers' compensation insurance, as required by
Settion 3700 ofthe. Labor.Code; for the performance of the work for. which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier 5TAT&r!UW.D Policy No. 046-113MOW
(This section need not be completed if the permit valuation is for $100-00 or'less).
O I certify that in the performance of the work.for which this permit is issued,
Fshall not employ any person in any manner so as to become subject to the
Workers' compensation laws of California, and agreethat-if. I should become
subject to the workers' compensation provisions.of' ection 3700 of the Labor
Code, I shall forthwith comply with those"provisions.
Date:. Applicant—
Warning: Failure to secure Workers' Compensation coverage is unlawful and
Shall subject an employer to criminal penalties and civil fines up to $106,000, 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 issuedas
,,as"a result of this applicaton agrees to, & shall, n
& hold harmless the City of La Quinta, its officers, agents and I Be
2. Any permit issued as a result of this application becomes nulla t aid
. f
Work is not commenced within 180 days from date of issuance -f t6ch-
permit, or cessation of work ,for 180 days will subject permit to ca II tionJA
I certify that I have read this application and state that the above info ma on is
correct. I agree to comply with all -City, and State laws relating to th buildirU191T
construction, and hereby authorize representatives of this City to r u onFIEV
the above- me riiiqned property forinsp6cti6hpurposes.
Qi nat Date
.BUILDING PERMIT PERMIT#
DATE. VALUATION LOT TRACT
$2.20X'41.00 38 GJ457 -3
2
JOB SITE
ADDRESS 119-646 M1r61S1Q1Nr]Y=Vr RAVI
APN
OWNER
CONTRACTOR /nESIGNER/EN61NEER
'173 VRRUrF TAVELORN"T
tnNRKS COMMUCIPM
PoBoxi-11c, -_ ..
7.9-2 95 10NICTIO A QXMA DF,
LA QT)mw CA 92253
LA Q'U'WrA C -A. MS3
USE OF PERMIT
MWLILK VAV49-Y VV WXING'
,,--FD . Ldr n, PLKm mi, PEPIALT V61=1407 WCL.U'DE )SIX)Ck WA),,L&
,Pool, orp.& O)t DPL'qZWAY rAp PR.0.4C14_ 7r% PtIAX Cfffe"CK pze
REPUCI-1014 FOR M1UUra-1LZ,T,SSUANCE0Y3A1 1 PLAIN TYPE
CUST0?4 CON19TRUCTION .14101.00 V
PORCHPATIO 267.00 SY?
0AftMJEk,A, ,PORT 614100 P
11mmum con ay? c6ralt R -M -10H
P=WT 71ra ma"Ry
CON" TRVOTION FER 101 -600-4 18-000 sl,ov.oa
PW4 CHIKAX FX9 101-000-439-319
MKILANICAL VMR 101-000,421-000 SIM04
PLUMBINO P99 101-000-419-000
P11 '22.69
0".0140 MOTION RESID 101-000-2AI-000 $
GRADIXO PH, 01 -MO -423-000- V5100
010Y_R�LITTKR IMP.&C.T FEE
ART IN PUBLIC PLACES WIL 7,70-000.445-000
4,
LESS PU-
A\
MrAL rMIZUr R7018 DUN
T4,22L,
-H
' 2 2 2003
U�f
WIT
PT
17
RECEIPT --rATE
DATE FINALED
INSPECTP,,0
L
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
3 - j — 3
Return Air
Steel
Z 2
Combustion Air
Roof Deck
_ /O — 3
Exhaust Fans
O.K. to Wrap
5 _ o _
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Lines
Party Wall Firewall
7zCondensate
Exterior Lath
Drywall - Int. Lath
Final —
Final
�3
POOLS - SPAS
BLOCKWALL
APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
/ j
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
7 _ 3
Appliances
Final
COMMENTS:
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 2 z
Utility Notice (Perm)_' , ..