MISC (0312-111)LICENSED CONTRACTOR DECLARATION
I hee@by 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
674(71% B 11110 7/31/03
Date f.> / `` " 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 , Sionature 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
( )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 STATE FUND Policy No. 046-793"03
J (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
3 subject to the workers' compensation provisions of Section 37001of-the Labor
Code, I shall forthwith comply with those•provisions:"^t' fj
Date: i ? ; P % L, .� Applicant s'`
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 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..
ignature (Owner/Agent)- Date ,>
BUILDING PERMIT PERMIT# 10
DATE VALUATION LOT 0312A.11 TRACT
1. ;J :7�,. , r ' . SV14,;i.90AO 59 29283
JOB SITEAPN
ADDRESS .�...—��.y M�;vv MWS�9��LJ .T)RMX? VMS1r.
�.�...C.4:b67
OWNER
CONTRACTOR / DESIGNER / ENGINEER
9'D DEETER;I't3EV1 t..0 PMENT
SPARKS CON 9"siM.MON
PO Kr+b 1716
79.295 RANCHO LA QU114 A DR.
LA QJ 3 . A Clk 92253
1. % gtrim% CR. 92253
(760)771-1941 tCBVI 2,996
USE O�F�P•�tEE�RppMIII�T+sTy'
SU FPLITAIJ. IT1i1, '1't:►1aP,RNII T,# 0 30 t <1 i4 R9FL•ECTING MAN 09 OF 1'.1.,A N ,
TYPE FROM ONR TO E1 l )TH R2 GUEST MOL 09
COSTOM OONSTAWT1014 t 120.0 81+'
105,00 SP
0ARAOMMIPOKT 14 .0(1 :el•
F1511MMID COST (YY CON9.1MMON
11,4,1.90.110
PLAN 0MIECK FEE 101 4000-4.36318 5894.13
CONSTRUCTI aN N'L.:: 1014000-418-000 $wom
MCI HANIC,°.f1;t4VEB 101•,000-421.000 $10.50
` ELECTRIC A1, fg2 101-0011,420-0010 $29.87
fi LUMB11-4C1 ,193:F 101-000-4.19-000 $59.,30
STR01401,Y..01f(YIJ 1?FZ - P?.ES10 101-CIOO-241-000
t
.,n.� I-MT1q., COMM tMl'C LION AIM PLAIT C.HECK
a l.�S PRU-1'A1ie s 0
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/n1
DEC 29 2003
CITY OF LA QUINTA /
FINANCE DEPT. ✓/
RECEIPT
DATE +•
BYDATE
AL
INSPECT
'IN'SPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms &:Footings
Slab Grade
Steel
Roof Deck
— 0� _ .9�
�l,yi
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
OX to Wrap
F.A.U.
Framing
Insulation
�_� _
/ v
Compressor
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
PLUMBING APPROV LS
Condensate Lines
Party Wall Firewall
_
Heater Final
Exterior Lath
Plumbing Final
Equipment Enclosure
Shower Pans
Drywall - Int. Lath
OX for Finish Plaster
Sewer Lateral
Sewer Connection _ y
Gas Piping z
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
Gas Piping
PLUMBING APPROV LS
Gas Test
Electric Final
Waste Lines
_ �� �6_ D
Heater Final
Water Piping _ _ _ _
Plumbing Top Out a--,, 1z
Plumbing Final
Equipment Enclosure
Shower Pans
OX for Finish Plaster
Sewer Lateral
Sewer Connection _ y
Gas Piping z
Pool Cover
Encapsulation
Gas Test
I Final
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Roush Wirina N S., LJ
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice
Final
COMMENTS: