ELEC (0312-114)LICENSED CAN7RACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Swtion 706-0) of Division 3 of the Business and
Professionals Code, and mp License is in full force and effect.
License # Lic. Class Exp. Date
64 1498 D21IL
A
Date �f�Sifna�ture of Contractor
OWNER -BUILDER
DECLARATION f
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 hdf" by 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.
( ) Dave 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 STAT r;,-40MITMIATI Policy No. M17412-03
(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 subjectrto the
workers' compensation laws of California, and agree4at ifIt�sh�orrd�ecome
subject to the workers' compensation provisions ofASectio Y37,0,of�the Libor
Code, I shall forthwith copply with those provisinc
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 la7lrelating to the building
construction, and hereby authorize representative tKisc ity, to enter upon
the above-mentioned property for inspection purpes
''
Signature (Owner/Agent) ,r-.�'/t Date f � f�
BUILDING PERMIT PERMIT#
w 0312-114
DATE VALUATION LOT TRACT
/t.1C, iK .$51000.00
JOB SITE c+
ADDRESS A-7
APN
764-0104M
OWNER
CONTRACTOR / DESIGNER / EN 1NEER
CAJ.,W.E.Err RAW
RcTi� Mcg),TR0.T"-; Urf wwr
P,O, 130X 06 KMA414, CA 93630
LA Q: dWrA . CeA 92253
Y.; MAM CA 93630
f
(559)846-3326 Ci3I�#
USE OF PERMIT
z.
1:5 HI'.�k31'ft"Lti�'!fY AS, "41f4i#� Ia f' ,C :1 N+t .t f °�S,'f`im 1S
VALUATION
L °Jf A `E'L"� C t5 1' t3 air t ' :T iaas
,t ).€ 0
YERN , SUMMARY
((3�'`pp�yy'.
p* ��-aa 33 ��+ ��yy //�� /dry �(� 06100 p ;1
HCFC! RICIA L FE 'A 01 "`4.�00-4#..M`�+TyJi:.0 e" '��6100
P[:D:EC
11 2003
CITY OF LA CZ:1 N1A
FINANCE DEPT.
ar.'IUM-YCFTL11..• FivOX.dRY.JP.A..t,l/.191.CtiA'R'O PL" CL.MAX
$2600
�3 Pik -ptiSi R
$010'
TOUAL VIERMIr FZZ&VITF NO
$26.00
45,ECEIPT
DATE t
BY-,
DATE FINALED
INSPECTOR
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
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
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
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
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Law Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
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BUILDING & SAFETY DEFT.
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OF Rr�f COU.' OF RIVERSIDE
J2 Ri9�
Depar . nt of Building and Safety
y 4 B �LDING PERMPT
god SAIF
This permit shall a 're by limitation and become nul ,,a, void if work is not commenced and a written uest for inspection filed within 180 days
from the date of issu e or if work has been suspe>I ",";'!orVabandoned for a period of 180 days between
e filing of written requests for inspection.
❑ LICENSED CONTIACTORS DECLA".
Chapter 9 (commencing"' th Section 7000)
License Class �1 Lice]
o.
I hereby affirm under penalty of per'/ryry that I am licensed under provisions of
n 3 of the Business and Professionode, and my license is in full force and effect.
Date Contract N
❑ OWNER -BUILDER DEC, RA I hereby affirm under penalty of per" that I am exempt from the Contractors Liffe i aw
for the following reason (Sec. 70 ess and Professions Code: Any city o ounty which requires a permit to construct, alter; improve,
demolish or repair any structure, pi`; its issuance, also requires the applic for such permit to file a signed statement,fiat<heor she is
licensed _pursuant to the provisions o ;Contractors License Law (Chapter 9 mine icing with Section 7000] of Division�3 ofthe Business
and Professions Code) or that he or exempt therefrom and the basis for a alleged exemption. Any violation of Seer17031.5 by any
applicant for a permit subjects the Y;'' nt to a civil penalty of not more an five hundred dollars [$500].):
❑ I, as owner of the propert °my ployees with wages as their a compensation, will do the work, and#ie structure is not intended
or offered for sale (Sec. 70usm and Professions Code: Contractors License Law does not appil', oto the owner of property
who builds or improves th regn, and does such work him or herself or through his or her own,emp�oyees, provided that such
improvements are not int d or offer for sale. If, howeve e building or improvement is sold w,�rtliin one year of completion, the
owner -builder will have J" urden of pr
in that he or she;' d not build or improve for the purpos&of sale.).
❑ I as owner of the pr am exclu ly contracting tth licensed contractors to construct Ile pproject (Sec. 7044, Business and
Professions Code: Th 'ntractors Licee Law does n -, apply to an owner of property who builds or improves thereon, and who
contracts for such pro '"with a contracto licensed p rsuant to the Contractors License La
❑ lam exempt undec. B.&P. r this r on.:
Date wrier
"
r.
WORKERS CO SATION DECLARATI I hereby affirm under penalty of perjilry;one of the following declarations:
❑ I have and wil ntain a certificate of Conseil elf -insure for workers compensation, as provided for by Section 370 of the Labor.
Code for the er
�ince of the work for whiq,'tthi .w rmit is issued. q'
❑ I jlave andpw' aintain workers comppens ton in ance, as required by SectloVC8700 of the Labor Code, for. the performance of
the work for whi his permit is issued. My;:" orkers e, pensation insurance cairxeir and policy number are:
Carrier Policy N er �.° (This section need not be completed if the permit
is for one hundre ollars or ess 3t
g
`,
❑ I certify that in the per ormance oft ork for which permit is iss�u , shall not employ any person in any manner so as -to
become subject to the workers compens, on laws of Californ and aggree tha I should become subject to the workers compensation
provisions of Section 3700 of the Labo ode, I shall forthwit ,A mply witl�iose provisions.
WARNING: FAILURE TO S/ECU, COMPENSATI VERAGE IS UNLAWFUL, AND SHALL SUBJECT AN
EMPLOYER TO CRIMINAL PEN TIES AND CIVIL FINES U e' ` NE HUNDRED THOUSAND DOLLARS ($100,000), IN
ADDITION TO THE COST OF C. MPENSATION, DAMAGES PR, DED FOR IN SECTION 3706 OF THE LABOR CODE,
INTEREST, AND ATTORNEY'S; EES. Vit,
CONSTRUCTION LENDIN AGENCY: I hereby affirm u altv of p 'ury that there is a construction lending agency for the
performance of the work for ich this permit is issued (Sec. 3
Lender's Name
.id
Lender's Address F'
CERTIFICATE OF C LIANCE AND AUTHOR ION OF ENTRY: I cert _ hat I have read this application and state that
the above information is correct. I agree to comply wit ounty ordinances and state la elating to building construction, and hereby
authorize representat' of this county to enter upon t ove-mentioned property for insp' tion purposes.
Sip -nature of 1FDliCant or Apent tv scan pent Name 15.. Date
INSPECTION FORMATION: Work may proceed only at the direction of the field inspector. To request inspection of work completed, call the
appropriate a listed berowUu_r office hours are 8:00 a.m. to 5:00 p.m., Monday through Friday. �.
West C unty: Riverside Office909 955-1800 South County: South County Office (909 6100
East unty: Indio Office (760 863-8271!.
REINSP TIONFEE: Reinspection fees maybe assessed when the permit card is not properly posted on the work site, e,approved plans are not readily
avaia e to the inspector, for failure to provide access on the date for which the inspection is requested, or for deviating froin,plans requiring approval of
the Building Official. A reinspection fee may be assessed for each inspection or reinspection when such portion of work for, which inspection is called is
not complete or when corrections previously called for are not made.
OCCUPANCY: Buildings or structures shall not be used or occupied until the Building Official has issued a Certificate of Ocancy (or for residential
we ind�' g�ign-off ofthe final inspection on the job card by the building inspector).
284-208 (09/99)