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LICENSED CONTRACTOR DECLARATION
1 -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.#. Lic6128 . Class Exp. Date ,,
1 104 -
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:
( ) 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).
( ) 1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code). 4
( ) 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
Se •tion 3700 of the Labor Code, for the performance of the work for which this
permit is iassue d.LMy wkoLker,s;1rompensation insurance currier &�policcyf no. are:
Carrier 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 3700 of the Labor
Code, I shall forthwith comply with those.provlsions.
Date: Applicant 7r tj
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 fovi lspect�ction purposes.
Signature (Owner/Agent) ��- f'/ :�+ Date—/
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- - � i%'` • "' yet' .'K
;cDING PERMIT PERMIT# -��
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'..DATc ^ f; ALUATION 522, 1.(X) LOT TRACT
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JOB SITE a %:� .�' . JM .r�:aXs.EXLV
APN - -
ADDRESS
OWNER
CONTRACTOR/DESIGNER/EN (NEER
Tt1ATt•. *Y.Pa"iT4E+,>Ea,�°.SORT COW. UMI :8, M.
�.`.AiC.ikO*:d�l�a..Y100.L a & �"I:AS CMIP'MAN X01
200 L, W,A,DIMMY ON AVE 0100
86.100 AV'MgUE 5h
:ir+iCOND-TZ 3 CA 92425
t::i).P,MM:1,LA CA 922,46
C?60)398-9222 ^t L4 00351
USE .�FOF. ;PERMIT
�:ill
Pn ll AV6 PRA V Illi V ri'11f9 A -MIX. -I
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.:i,t. A,W VGARJ1t%1;'5 SHALLBE lid PLMT t'1'.lCIR TO'PRLPLASTER
POOL .E1NDACIR SPA. 221000100 12
MrIMUM COST Ole C'OatilS°9R'>rTMOR
22,9W,01)
PLAN CHECK MI E 101.000.439.31 @ "' $146,23
C cYNS`f',RUC::` ION .F'FI:• 9 02 -000.4't b-000 $223.00
MUCii NICALITE. POOL 10)-COO.421.000 $ 4,DO
ELXC"I'MC:AL ME — POOL 101-000-420-000 $4.5.00
PLT1.rt+ll INO 17119 •- POOL 101.000.419.000 $27.00
.. OLM-T 3TAL COMI;�'.UG'i"'C. ON AWD PLfi +t ClIECK
i-161.23
=193 PFMIPAW kr s
$0,00
ViTS ]DUE! 110W
9467-75
APR0 6 2004
CITY OF LA DEPT. /
FINANCE DEI>T.
RECEIPT
DAM�4 tt%
BYi•�
DATFyFIN ED
INSPEQT9R_
T.,
INSPECTION RECORD
OPERATION DATE I INSPECTOR OPERATION I 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 & Controls
Party Wall Insulation Condensate Lines
Party Wall Firewall
Exterior Lath
Drvwall - Int. Lath
Final
Set Backs
Footings
Bond Beam
Final
tate ones
BLOCKWALL APPROVALS
PLUMBING APPROVALS
Flumbing Top Out
Shower Pans
Sewer Lateral
Sewer Connection
Gas Piain9
Final
Steel
Electric Bond
Main Drain
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Gas Piping
Gas Test
Electric Final
Heater Final
Plumbing Final
Equipment Enclosure
O.K. for Finish Plaster
Pool Cover
POOLS - SPAS
Final
COMMENTS'
Final
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temo: Use of Power