The URL can be used to link to this page

0310-024 (BLCK)LICENSED CONTRACTOR DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and C1I W Professionals Code, and my License is in full force and effect. O ch License ## f �yLic. Class +/jj Exp. Date �p y r` 682901 .iJ W31 /21f Z r Date lr� � r Signature of Contractor- --: ((0�� J U C:) OWNER -BUILDER DECLARATION LU W r1_ I hereby affirm under penalty of perjury that I am exempt from the Contractor's ~ tlCn License Law for the following reason: Z_ ( ). 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). ce) () I am exempt under Section , B&P.C. for this reason U1 N Date Signature of Owner ON rn d Q WORKER'S COMPENSATION DECLARATION p 2 11 1 hereby affirm under penalty of perjury one of the following declarations: U1 O ( ) I have and will maintain a certificate of consent to self -insure for workers' X UJ �= compensation, as provided for by Section 3700 of the Labor Code, for the O � Q performance of the work for which this permit is issued. C0 Q L) ( ) I have and will maintain workers' compensation insurance, as required by O U Q Section 3700 of the Labor Code, for the performance of the work for which this f— permit is issued. My workers' compensation. insurance carrier & policy no. are: ,It z Carrierob E5 q`!Xf.E Ft, HD Policy No. 229- 00IM 2003 �O 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 3700 of the Labor Code, I shall forthwith comply with those provisions. Date: 111 1 Applicant— Warning: pplicant 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 I 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 k* 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 authorizejrepresentatives of this City to enter upon the above-mentioned property for inspection purpdses. /Signature (Owner/Agent) Date BUILDING PERMIT PERMIT# DATE VALUATION LOT 010.07. TRACT 3.(b1d32+".I;fiC �i,UEH3.t30 11 . JOB SITE APN ADDRESSS4^44� Ai+'fN1Da ('ATtI' t�T�T .A 7'l�R $?r 021 OWNER CONTRACTOR / DESIGNER / ENGINEER RO, BOX 134 41-�aG 131�+tixTAOxF 2��c LA QUfNT A CA 92253 i31:RMMA z3WEZ CA 92201 (760)409-7328 CB1,4, 3724 USE OF PERMIT G:I;MRAL I11..1],T.,iS.WO 130 Lir COMBO BO 2' RETA1NF?#M' 0A1RS:"tlMN "WALL cis 50 .LFP 8' CLA,F DEN WALIeC7I' Y STANDARD 6 FT. WMIL 200,00 by i;M34+A:A`T`I D COST af,' COPM, W110.11 rMMUFM SUMMARY k 014 3TR.UCTION FEE 1 Q 1.OW 41 F3.00O Mr. on ,V.,• t,MONAND Pt.,.4AT CHECK $72.00 p o 1X53 PRE-P.AID.PriFZ OCT 0 2F�.2063F:_f�x� Jaz Now .00 I CITY OF LA QUINTA I FINANCE DEPT. RECEIPT DATE m BY DA;EYINAD INSPECTOR INSPECTION RECORD c .OPERATION OPERATION DATE DATE INSPECTOR INSPECTOR OPERATION OPERATION DATE DATE INSPECTOR INSPECTOR BUILDING BUILDING APPROVALS APPROVALS MECHANICAL APPROVALS MECHANICAL APPROVALS Set Backs SBI Bach Underground Ducts Underground Ducts Forma 8 Poolings Forms 8 Footings Ducts Ducts Slab Grade 51ab Grade Return Air Retum Air s� Steel co�,e��oo Air Combustion Air Roof Deck Roof Deck Exhaust Fans Exhaust Fans O.K to Weep O.K to Wrap F.A.U. F.A.U. Framing Framing Compressor Compressor Insulation Insulation Vents Vents Fireplace P.L. Fireplace P.L. Grills Grills Fireplace T.O. Fireplace T.O. Fans &Controls fans 8 Controls Party Wall Insulation Part/ Wall Insulation Condensate tares Condensate Lines Pa Well Firewall Party Wall Firewall Exterior Letli Exterior Lath Dryuvall -int, Lath oryweu - im. um Final Final Final Final BLOCKWALL APPROVALS BLOCKWALL APPROVALS POOLS -SPAS POOLS -SPAS S�� steel Set Becks Set Backs Electric Bond Electric Bond Footings � Footings /Lu — Mala Drain Main Drain Bond Bim Bond Beam 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) c .OPERATION OPERATION DATE DATE INSPECTOR INSPECTOR OPERATION OPERATION DATE DATE INSPECTOR INSPECTOR BUILDING BUILDING APPROVALS APPROVALS MECHANICAL APPROVALS MECHANICAL APPROVALS Set Backs SBI Bach Underground Ducts Underground Ducts Forma 8 Poolings Forms 8 Footings Ducts Ducts Slab Grade 51ab Grade Return Air Retum Air s� Steel co�,e��oo Air Combustion Air Roof Deck Roof Deck Exhaust Fans Exhaust Fans O.K to Weep O.K to Wrap F.A.U. F.A.U. Framing Framing Compressor Compressor Insulation Insulation Vents Vents Fireplace P.L. Fireplace P.L. Grills Grills Fireplace T.O. Fireplace T.O. Fans &Controls fans 8 Controls Party Wall Insulation Part/ Wall Insulation Condensate tares Condensate Lines Pa Well Firewall Party Wall Firewall Exterior Letli Exterior Lath Dryuvall -int, Lath oryweu - im. um Final Final Final Final BLOCKWALL APPROVALS BLOCKWALL APPROVALS POOLS -SPAS POOLS -SPAS S�� steel Set Becks Set Backs Electric Bond Electric Bond Footings � Footings /Lu — Mala Drain Main Drain Bond Bim Bond Beam Approval to Cover Approval Cover Equipment 1lMatlon Equipment Location Underground Electric Underground Electric Underground PI .Test Underground Plbg. Test Final Final UL Gas Piping Gee Piping g PLUMBING APPROVALS PLUMBING APPROVALS �'�T`� Gas Test Electric Final Electric Final Waste Lines Waste Lines Heater Final Mala Final Water Plein Water Piping Plumbing FMeI Plumbing Final Plumbing Tap Out Plumbing Top Out Equipment Enclmure Equipment Enclosure Shower Pana Shower Pans O.K. for Finish Plaster O.K. for Finish Plaster Seger Lateral Sewer Lateral - Pool Corer Pool Cover Sewn Connection Sewer Connection Encapsulation Encapsulation Gan Piping Gas Piping ' Gas Test ' Gas Teal Appliances - Final Final F�� Utility Notice (Gas) ELECTRICAL APPROVALS Temp. Power Pole Underground COMUG Rough Wiring Lwv VW18ge Wiring Fu4ur88 Mein Service Sub Panels Exterior Receptacles G.F.I. Smoke Detectors Temp. Use a� Power Final Utility Notice (Perm) COMMENTS' COMMENTS: / L7C3 p� - c