SFD (0306-074)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
7769.9 13 4kl0104
Date 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 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.
(y) 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 T:ll3kY�'TY MUTIJAL F Policy No. 'IAT.A,XIDDr.1i7.230UT
(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.
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant
any permit issued as a result of this applicaton agrees to, & shall, indemni D
& hold harmless the City of La Quinta, its officers, agents and employee
2. Any permit issued as a result of this application becomes null and void
work is not commenced within 180 days from date of issuance of suc
permit, or cessation of work for 180 days will subject permit to cancellatio .
I certify that I have read this application and state that the above informationi
correct. I agree to comply with all City, and State laws relating to the buildin
construction, and hereby authorize representatives of this City to enter upo
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) Date
BUILDING PERMIT .PERMS f
4rx
DATE VALUATION`t�`7!$�il;l LOT � � TRACT
JOB SITE.�n�t •a�
ADDRESSJ+.�►aY1ucr.rs!.er s.t�k�
APN 762-410-W4i-�}�
OWNER
CONTRACTOR / DESIGNER / ENGINEER
V &L BIP03.1 ti INC
T0111 BRUMEMB DIC
72s-- 23 .TYRktDAA'A'3WG#190
7:1w'±2] 7 -RED WARUI 4100
CA. .9?,26u,
P.Aj.. Af rJT'?:S`Ft T.sT CA 92260
('Ifr31�'��•��$�a�' 't��I.t� �f3�2
USE OF PERMIT
11
ie.IJ o L&J1 et V ZPJ
C)I,rM:.l; 1VAJ WY1;'_)e0f4 ,9NA
TO )PI.4A�I t". HXCK 7,! ME- TO AdiiSLTIPIA ,!5"?']I.f. J?V!! Of SAME P1,AIN T'. PE
P011CWPATIO SY
0.A.Xt&0ZX.hRf-0Wf iii
111.12COIGIC FRY 9V WVA&RIV
R 101 -000-4181,000 $1,356.90
:W�'�yj�MA��))2�i/lRi��.".1CQAG � t� i ��E�f`)4` <q01://:��-000
u�'Ti
I.�it,74?C f 4$1.�4J. F'1�J'K:
PLUM91140FEE - TU . KV, 19.000
STRONC MOTION e3"t tRPSID 101-000-24.1-000 �IrS.Ig
GRADING Fr;17,
X02- ILOPFIR.11MY.A= PER
ART Ill PUD941C V +«4(28 - RNSIL 270-000.445••000 WK W
4'1,3.,z,5m
ix. 011 FRE -PAW FWD
Vln. 0
T rTIALP.r'W1u'rFE�'�?�W�'''.'`d?'i9
JUN lg 2003 V
CITY OF LA QUINTA
FINANCE DEPT. 1,`"
S%
RECEIPT
DATE t �,_;
^BY {
Dl's/EF�IQt($LED
INS TOR
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
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 Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines 3
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection 7 a3
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: