0402-051 (BLCK)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 r Exp. Date
778280 }� ,' l 3 311.2(
:�-0�
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). ✓1
( ) I, as owner of the property, am exclusively contracting with licensed I
contractors to construct the project (Sec. 7044, Business & Professionalsa
Code).
( ) I am exempt under Section B&P.C. for this reason n
Date Signature of Owner i
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:
Carrier EXEMPT Policy No.
(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 37 �fthe Labor
,Code, I s all fortrwith comply with'those�rovisionsi }
Date - U S 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 LaborCode, 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 prope • for inspection purposes.
Signature (Owner/Agent ��' .+%� '—'�—Date
BUILDING _ PERM' :4 :. %
-PERMIT
i s �
DATE -- _.. VALUATION LOT - I ry TRACT t K
'250.00 71.7
JOB SITE
ADDRESS :57--0 0 AVE—RAWZ
APN 773-222-M
7. -222- �vt�
OWNER
CONTRACTOR/DESIGNER/ENGINEER
RAWID if' LAILLS
:LE.OACY HOMES
54-865 AVd:MDA 0.BREGOIN
P,U, BOX 696
LA QU'XWfA CAA 92253
LP.QUDITA CA. 92253
i
(760)564-7820 C331.6 02063
USE OF PERMIT
1:30 LF COMBO 3' RZTA1NI!gG WITH 5! DAl OIrW WAll, AND 120 LF b'
GARDEN WALL PER CITY,3TANOARD. WALIA WIT14IN FRONT 10' OF
PROPERTY UN% HA1lE A M AX"IIAUMt H_1?IQHT OF 5'. 2001 CBC.
6 PT WALL 250,00 LF
� f
,r
1rSDWA.TX.D C O.';V.0 OF i't?1'TG.RUC I10N
PERMIT h�r.'S+•.WM]m;i.4i7F Y
CONSTRUCTION FFY_ 101.000.418-000 540.00
FEB 0.6 2004
C ITY OF LA QUIWA
F1NANC DEPT.
•
f
STAB.-TOTA;L'. COW_ T7(7.i109 AND PLAN CBECIC.
$190.00 '
LAS 1:'RE•aFPJD FJMS
$0100
.0
RECEIPT
DATE .. �, j
B
DATA FINALED O
4
INSPECTOR .
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts r
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
�iO.ci PL
Underground Electric
Underground Plbg. Test
Final
.v
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
E,Gas Piping
',Gas Test
c
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
LM14 Notice (Perm)
COMMENTS: