SFD (0302-038)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.
,,bcense # • Lic. Class Exp. Date
7 07699 4/30/03
,Date �* •'P Signature of Contractors �
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
. r
I hereby affirm under penalty of, perjury one .of the following declarations:
(..) 1 have and will maintain a certificate of consent to self -insure for workers'
compensation, as provided for by Section 370.0 !of the Labor Code, for the
performance of the work for which;this permit is issued.
Zion
have and will maintain workers' compensation insurance, as required by
Section 3700 of the Labor Code, ,fo'r the performance of the work for which this
permit is issued: My workers' compensation insurance carrier & policy no. are:.
Carrier ;,1f ERTY MUTUAL F.' Policy No. WA2621DOM 30112 a E
(This section need not be completed if the permit valuation is for $100.00 or less).
( ). (.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. N
-Q
ate: Ir- Applicantf��P
Warning: Failure to secure Workers' Co4ensation 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
fora 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 t0
any permit issued as a result of this applicaton agrees to, & shall, indemni
& hold harmless the City ,of La Quinta, its officers, agents and employeesY
2. Any permit issued as a result of this application becomes null and void 'f
work is not commenced within 180 days from date of issuance of sue
permit, or cessation of work for 180 days will subject permit to cancellatio .
I certify that I have read this application and state that the above information
correct. I agree.to comply with all City, and State laws relating to the buildi -
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature Dates a
BUILDING PERMIT PERMIT#
DATE VALUATIONLOT _ TRACT ;035
JOB SITE?�, y�
ADDRESS ; 2,' :omna 9'�1'� k f. ou
APN
OWNER
CONTRACTOR/DESIGNER/EN 1NEER
WTI, SJ O Ab'lM"' INC
�c d.4 �., x�..FG.cAMP) C ,
7 1.21 ;tMED lF7,t3�'-.1�K4 Al00
73.121 FRF- WA�_ 3.MIG #4
PAW DESM.'r CA 9226A)
DESERT CA 92260
(76Q)674-9699 CTLN ?832
USE OF PERMIT
. ).+0T 5111 BRiAILP - A. PERMIT DOYS 1401, ,iNI.".Lt7DE POOL,
Itf.1,D TION f'iirK'SO MUL^11PLI� 19.31JAHCR,, OF SAKE $11,,.14 TYPV-" -
62TOM CONST'RWIMN ',,047,0 SW
�Ofi.C:Irf��A'I'tC;t •'t`,`f il3.if� .�+Ir
UZIMIX-033 6::ONor F C IDNI RR117MON
tN'[1MMARY
t tl TT33xc f' }l FEE 101-000-418-000 $1478.50
e?if:.s�� Gf�'�,rC'.IC :P�'>r+"- f +?i +•CQe;>:•�' ��?-'� 1 gS ��.'14.�
';Vl'r CH1 WIC9AL FKX 101.000.421-000 $150.00
iLF1C'1r.RGFLIP, 1. 011 - 900,4 2 (4f0 4194. ,5
/0-419-000 S203125
PLVMPINO zEF101a0
S'TI:ONO'MOTION FEE - RFS11) 'j 01-000-241 ••Ut7ti ���..,�3
GRADNO FPH
6EV Y O-PlUt
ART E11 ryi113.UC P1,ACM - MIT 270-000-44-5-000 $134,44
IMM 7Wi' L C;C)N'STR'CTM109 MW .K:,Al'1't`I `.CK,
.l , 50_1.9
FEB
2 0 LY
CITY OF LA OUEev.`t A
FINANCE DEpT;
RECEIPT
DATE i N
'BY- EIN ED
SPECT
'i�•�,.L'.5i,
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
- , c
Exhaust Fans
O.K. to Wrap
_
F.A.U.
Framing_
_
Compressor JV
Insulation
Vents /
Fireplace P.L.
Grills K,_
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines AK
Party Wall Firewall
Exterior Lath
_
Drywall - Int. Lath
Final
Final
_ _
/
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 I
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
4p
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL
Temp. Power Pole
X OVALS
Underground Conduit
Rough Wiring
_
Low Voltage Wiring /
Fixtures
Main Service
Sub Panels
Exlerior Receptacles
f/y
G. F.I.
Smoke Detectors
Temp. Use of Power
_
J— -�V — - —
Final
Utility Notice (Perm)
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