SFD (0301-103)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
A'�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
&74074 131�i1i /'� 7/33/t13
Date f ��`� Signature of Contractor
OWNER -BUILDER DECLARATION e
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.
\,(,r) 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 3YA-1L? JVU.NL) Policy No. 046-IMR-203
(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'.'- i Applicant—
Warning:
pplicant Warning: Failure to secure Workers' Compensation coverage is unlawful �nd
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 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 relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes. /
Signature (Owner/Agent)''•
1..J•1I/
BUILDING PERMIT PERMIT#
l►3d114a
DATE VALUATION s282,1()6.00 LOT 48 TRACT 1,11,92 8.4
1
JOB SITE ADDRESS yJ. - '. �}IO AV I�� `7�.�� i+F7�
APN 649-2710-067
OWNER
CONTRACTOR/DESIGNER/EN (NEER
TDDES i-1�i°T,1EMOP -
1141A XIIS CION :r tMITION
PO:FSOX 1710
/9.295 ?iATMO1AS'iQU.INTADR,
LA QUWA CA 902253
LA Q MRTTA CA 92,253
(76L1)771.1941 CW10 7199151
USE OF PERMIT
"WAX AX FAMILY DWW.Li_xG
Sib+ P I..OT 43, MANA41. F' yJ�M:tY tJ2 i�� EdD'C i IOI UI)F' 1I I Of:'x::
WAA,LS, F"0014 21PA OARIVINAY APPF+':OA.I"H, '"P/o ltEDU'.Cf10H TO PUA.1,i
CHECK ME 1iM, TO MUiJTlPLE, ISSLIA14CE OF SAME PT 47t+ TYI.9La
CUSTOM CONS RUCITION .s,.MiIOD 9F
POI,.C,WRA` IO 5130100 V
OA .Oi3i A42Pt?18'i' 693,01 OF
E)tJ.dAt•513:�.E:* ®�i(.i. r WS:,'41 1"I �rlti�A', ON
n�i82,1:�i'i4.�'.�
ysY���t ���p Ay3�riKpl
t1y A��p�p. MIR
'A-,{N+ri.Ta.4YkX.A� Ttl YIR 69V-IY.iL'�.68:t.L>i�
CONSTRUCTION FIEF 1P3IniOCIO-418-000 $1,38D.00
PLAN CBECK' F&1, 4101t -000 -439 -SIO $2"23
MEC1;~IANICS.I, CHER 101.000.421-000 $140.50
MAJCTRICA1, IaI:E 101-000-420-000 11215.rol
PLUMBIHO FLM 101.000.419.000 SMZ24
STRONU MOTION FEE • RESID 101-000.24.1-000 $23.2:
ORAI31M RZE I C) i R0i1C i ; -001? $11
M-Mr,1I..01PER. IMPACT i'c E $�,4055.00
ART Thi PUSIAC PLACES - Tt1! it r/0-000-445-000 $205,27
•:kJ':aY+.CL.,+�f�y
7� y�'i� '. •�'. :.YV W6��,eA.d'►S'V.R•7 .Y�:6ah]k4� .+.C.
�p�vsf . 767
LEMS PA 1: W'' '
$0.00
I�
JOIN 2 q 2003 'Ib',� �+r�cl1';� r�:� � ���r
$4,764150
` V
RECEIPT
S
DATE _
i
BY X _
DAT FINALED
/-�
INSPECT
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)elf w /w: •�A
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INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
p — 3 S
Ducts
Slab Grade
Return Air
SteelCombustion
�(�--3
Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
zFans
& Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
71
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
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lin
f2 —1,2 —
Heater Final
Water Piping
ZPlumbing
Final
Plumbing Top Out
zEquipment
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: