0212-112 (RR)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
3 r t7 3 v �1'7131104
Dated r_ V0 Signature of Contractor'-
-1/
ontractor y=- - ----�
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.
"(, } I have and will maintain workers' compensation insurance, as required by
S tion 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 ;iTATERIND Policy No. P63540-02
(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
Code11`3ill fo tilwith comply with those prov cions.
Date: Applicant \, 1 L----, ---
Warning:
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety'
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application -is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days: will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives. of this City to enter upon
the above-mentioned property foNnspection purposes.
�r
Signature (Owner/Agent) Date
PERMIT #
BUILDING PERMIT
0212-i12
DATE "y'+-VALUA)'ION LOT A TRACT
�.Ff J. lE�QQ 4910�PFF�kf V ��Rl '
JOB SITEr
ADDRESS IM -IM LAVI O DRIVE
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
CION & MAR.i'r-LLA k��1'�14�`
Rci..}F Tl. IE Si EC3MITY,1R e—,
'78.0091:.AGO DME,
ro'B(sy;11 Z57
LAQGRTI,fi_ CA 92253
P!'j..liojr� )31.EAT CA
92255
("16C3>200-081 i CYE5X,1.`r
1420
USE OF PERMIT
OrAq'UIPJ.,
VAL;UNnON 00 LS
dS6i1i1q:4RiA$. 1D 4.'..r6Td. OF YM'6J}i"TIV3.+ �.r.1;10Jr'1
aP ��tJV'r9Tli
MRWHIM SUMMARY
DEC 17 2002
CITY
OF LA'QUINTA
FINANCE DEPT.
:' UB i°i11"3 & C01a.1 pwC':Ciaff Am 14"t,14 01—w I,-
DUE NOW
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
y
2-
V44
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
I 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 8 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
V'laste 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
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
Dee OG 02 01:20p
7. 'i 091;:JWitl ! 30 7602300901
COMIRACTORS STATE
P.O. EXXX 11257 PAUM LV4aj-, CA 92255
A PrOP-' Sdl Sulfalitted to: .DSIV
MWAing Addi mw. 7900't.AGO DR. LA Q1111=A-A 9225.1
lJob AddTC53:SAMEAS ABOVE
FAX
114xripdum Grout to "t PIerfortotd:
I INSTALL TApMW FOA.M Ila --IZF0LL01'FA>Tjjt3NF
-MICILIA-41CAL VASTUN
M&TAX LONE LAID (;LASS1 BASE.
iflISTALL TWO LAYWGLAS-i YLY 6 Wrl
INSTALL NEW loon JAC" A.Vil rEaJW.j'Ex mLrAd_(jE, pUlmip,
UTr MOV TWO 1--AMRS GLASS PLYTO EXFOVD METAL EDGES 0(CCWJX1PATIN0*Ir' ROM 111+'.kf.-%C1:
HU'r r" ONE EA)'KIt !!V CAP.
M.t.5T1C AND IVES ALL WITH f))t.ANVLXZ
WK
)y
J61IEWALN�
3 SLI
r. Tt)OWTM0 I-ANDAILIX4.
IF N01 A" LMD IN 30DAYS THIS PRUP)SAL IS NULL A -VD VOID
fts; In Kmpi% with hdAutry M&UPIt: 1. Thia PArmame does m cover any da mIAgv to tit.: intrXiot 0 r rXienor
wbxh the roof is app"& uv dazuW to any corlitnts jhm-m Thai gtMrAygMdjXsftActNffLIALGaveto)c)afdile
ally c4m"t;nd but not limited to: bn. ijjTj)u&& Witld5tujnk haij;[Cm, mem"or
Ier alnilxuotq foe ttadlie on roof, rdttiYucal faun or trttalautaac sacking or aper taiitm d the roof deet, a errs
fusmdullua of the 1111JU09 at wined the mufit aMfied- 2. Should It become rmutmy for tile jotlfuAg
,'UaCtUf to MWW allVOr ranglan My amrmu, coaling or tmimi; applmom or otitis squipmvae whether or
I as adddonaii cb&Tgt Tit MA& 101 nCh WaA4 Ow cosunner andcMumU OW llctlhtf ROC I TX- Specialty not The
-Wits Amro ss any sesponsibility, for the par Fb11a3fW0 of said OQUiplUtfIL .) Root `l'JI, Sp=i3jkv does art I&XITIC
VrciponsiWily forcontc-tions orvdstin8 code %iolations 151 for she ,Xjmix-ofd* t–tiswls &ACIS aftles,
W sr: S4,W4.00 (NOZAPERS3,51W-00) Terrm pInd on mapicdon "Men olIbCgwIje
=ficd
CqUilm: you are Im& ' v authoriavd to fvroihh all conims written is the contmet up oomvmc walk nxIlnPW4
9W pfopma] contract fat whieb E/Wit 68M 10 Pay I -be AMULa iwIliUrvA to said propusal, and according to
mstilt'vot,_ (Inifiao. TEN years fton,
of aPpI;4*ILftt, we will repair it ficc of clustga.
icalli-Aim h is undienagad that by ile ameptsom of this prollosai you authoji7-- Prof 'rile Speday in mu—kz The
Mlklfictb: to iMus work 00dW with Speftfimlium ewwn herein and to pay cur charge for such immilation You
roe ioTray Qts amount ftwmifiud)m%*k which will wvcr the price of said umverWs and law Gimp. 'Ibis
irrme is based on a complete jols and say surplus material rennins property of Poof'fjle SpecinIty. Vel Al
0emnlrdling mad k7=seoU vvjth.mpjcwaodvz W=U Ant be NAdulg urdegg so ford, jlerco. Ilmshw1bella
bilitisg for ddayS in, Of failUX to COMOV9. &hveT of a stvllefion of all or aft of the herein vicationsId
'Idiandise, irdue to fn, striker, way, gaftntatelft repiosiiomi' or any arose beyo2d out conuncl. ANY cha%Ws
KIC by YOU in SPBCtfieftlit)(111 VItt= hildiliarilt) nq"- 10 UbCPT GIU11 mA he included OK ctwemd
UUS MPOW, but shall be pfivided rot molur "Male 3-A gd&iuttal ream fmal y(W .__(Tnitinj
binatitafl OZ difptuCs: Amy CouLrOVtI'1y Or Claim aJtsi)tg uta of or reeling to the contract, to 0m heerdt ¢baniL
sit be satILd by artritrMy in sovorrtwxc with the applicable, Coosimclifin (It LWY Arbit%wr Rules of the
qencAnAmialabon Aisociatka which one iD d%4t at the time the dere nd for arbitration IS fttW. Ajudgmtmt
an,dieawam retukcedby theutWomlox(L) may Anywtitristioli
and ihaU Im atle" to correction "ot vacation fur the mawas statod in the crAe of civil Pracrilkim. The
)in-Aitta shall award Ttmuhbje attorneys filxs and exp== to dkc rin-vailing party. Met being F;mo due
!icg. ib.o;tid arty piety fad to appm al tit participew in ft mbitrator prwxdivzs. air wbAmtor sbou make an
am hand upon the: evitience presented by The puty(ies) who do (does) qpw and pdrilcipate. Xorwithstm&;�S
In the emozadefanlibyell Win
�r)tt;nt of Iba amount doe hacwrder, chord agrrs� to 1'01"3' rmsanahle attmtayS' i'Jyr'e rnd cost intticrreil in
viectloo with collection of said am*wtLs whether or not suit is filed, 1 5% pr mmt'b andlor an zitrml
low to be lktn$4:dv.d
=
duW *bD.jhYWc. Oxtitact Stato Hated Any question comenting a conerracum- cosy he rUcaitd to the register of
Road, Sticrautentu. Ca.. 95%r,.
ontractcr; Sm Umscs Board, 9913 (balltv
Ung Awress: P. OW sulartma"CA., 95326.
I' akAe prices,iffili and cull Usfaclo d am hweby accepted.
nil 2
MCI*, siqualusti Daft
flUTACrJYY!
Ittlactof S S= Dale: