0308-342 (RER)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 - Exl:.Date
rt y� y� y �f
1 �t'A:pli4 B TUC
Date f , ,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:
(. ) 1, 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
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:
Cartier Policy No.
(This section need not be completed if the permit valuation is for $100.00 or less).
(N)' I certify that in the.performance of the work for which this permit is issued,
I all 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 provlslons/
Date: `'% .'?� d �r Applicant
`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 authorizerepresentatives of this City to enter.upon
the above-mentioned property for inspection purposes.
J Signature (Owner/Agent) - f»`� -Date ��-_?
BUILDING PERMIT PERM'�32
DATE VALUATION LOT TRACT
JOB SITE
ADDRESS �_j24Y.xlG'
APN
JDSF—�1� �a
OWNER
CONTRACTOR/DESIGNER/EN (NEER
3475 126 AVENUR NE
78-105 CALLS Y.�XT)O `W '
I L S Vb'& 98005
1,A Qi3.l7TA CA 92253
(760)564.9959 CBIJ3 03905
USE OFPERMIT
jMSIDITJ JAJ, 4JEL
R.ZM01''.AL OF RXIST NO CW 1313 MZ1=A!r1-tZ8QX,'OUNTZR ADO VI'PX,
Ck„> 1 UAE
b Fr. WALL 7.00 ALF
a FT. WA J, LF
VALUATION 4M 1.00 343 .
4
1e Cpflop
lsnMA7D CY7duDIN91
i as Gild aN .
RWn ME M:1�S.;� ARY
PjAN CHIECK Fn 103-000-439.318 $6/4,35
CONSTRUCTION f1 9:0i-Uf30-A 18.000 $99.00+
ELECTRICAL FUe 101.000.420.000 $15.00
PLI;IMOINO FT 1 Cs 1-000-d 19 -0th $1&00
D
:.AUG 2g 2003
CITY OF LA QUIINTA
FINANCE DEPT.
TCi°I"1',1:. C014MRUC`I W A Pa�1W CIROC
9 :
MRS PRE-VPM FERS.
$0.00
'r,OTA . MWflrl"'M D'uv. SOW
RECEIPT
DATE
BY
DATEFINALED
INSPECTO
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
POOLS - SPAS
BLOCKWALL
APPROVALS
Steel
Set Backs
Electric Bond
Footings
la- Z-
Main Drain
Bond Beam /30 Ell
aApproval
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
COMMENTS:
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)
79-124 Liga,LeGuinta,CA 92253 CITY :OF LA QUINTA SUB -CONTRACTOR LIST �► apirrw�cTOR'SUCENSE#8161>IBB
JOB ADDRESS PERMIT NUMBER d 300,p-3YZ OWNER Stritmatter _ BUILDER Waxlax/Ryneal Interior Design,lnc.
This form shall be posted on the job with the Building Inspection Card at all times in a conspicuous place. Only persons appearing on this list or their employees are authorized to work
on this job. Any changes to this list must be approved by the Building Division prior to commencement of work. Failure to comply will result in a stoppage of work and/or the voidance
of building permit. For each applicable trade, all information requested below must be completed by applicant. "On File" is not an acceptable response.
Trade -CI ssificat n
1. a io
;. Contractor
:.State':Coritractor slice
I nse....
, ;. Workers Compensat
i` n.'Insurance'Cit
o
;'Business
License
Company NameClassifica
tion
License Number
Exp; Date
Carrier Name
Policy Number
Exp. Date
License Number
Exp. Date
(e.g. A, B, C-8)
(xxxxxx)
(xx/xx/xx)
(e.g. State Fund, CalComp)
(Format Varies)
(xx/xx/xx)
(xxxx)
(xx/xx/xx)
EARTHWORK (.642.}'`: `_
CONCRETE;:(C:=8):` : ,` ' ::
Bonanfant Construction
( -7—(-
(Q b5'
Xo,:;),
(p/04
coo 35-7
' (Wo
STRUCT STEEL (C 51 j •
s�
MASONRY (C 29)
Bonantant Construction
PLUMBING 6)
(C 3
Mable Leaf Plumbing
C �!o G Z�
8 3 3
03
�•a 7t W4 P
l 5 D -4-1
Vii.
66/71
a v�
LATH, PLASTER 1C351'
fAV
ELECTRICAL.(C 101 j
Hegge Electrical
G (
36
Un
0 UO (f 1 3--�j3
b/ 6
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in
4- 6�
ROOFING IC 9);::
EE
SHEET METAL
FLOORING .I0,15.1.;:;:>.;.,.:.;::,;.
INSUI.ATIOLV IC 21 '
SEWAGE DISP (C-42)
PAINTING 1C=33)
•
CERAMIC TILE (C 54)
MCG Ti 'd* Stone
ff(r
"1�'
I r 3o b
/
5 Fvnd
'2.�-9-c�z.- �-8�.5
!.� (��
C� �. (84
1 6
CABINET$ IC 61
:FENCING,"'(C 131
�,ANDSCAPING (C.,27! ...
POOL. (C 53)
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