0304-239 (RPL)0
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
5521,16 C53B:EI1:: ': 2n disc
Date 0 ' ' Signature of Contractor
OWNER -BUILDER DEC I ARATION
I hereby affirm under penalty of perjury thatVam 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 +',-i Signature of Owner
WORKER'S COMPENSATION DECLARATION
11 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 TTATF- lkI XD Policy No. MX18-W
(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 provisions.
Date: .t Applicant t '
Warning: Failure to secure Workers' Compensation coverage is unlawful
shall subject an employer to criminal penalties and civil fines up to $100,00
addition to the cost of compensation;,damages as provided for in Section 3
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Saf ty
for a permit subject to the conditions and restrictions set forth on s
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, indemnity
& 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
r 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 for inspection purposes.
Signature (Owner/Agent) ``•+ �_+ * +� y� Date 4ZI"'
;BOL ING PERMIT PERMIT004
DATE VALUATION rA:�lkl:r: LOT TRACT.
JOB ADDRESS
APN _
OWNER
CONTRACTOR / DESIGNER / EN (NEER
5���7'i`i�"''�f+Nl:3I'4'..s:�:?Jk�4�'�;4.E�A�+ z!.1�F".i•e"fat..
��.z?'i!C","J[�'C�"'�t_�C.fi�
v? -515 BLACK :11', ;9,M1 ,0D
39-301 BAL77.1<,' M2M. W.100
ZA oi u'rik _;f; 92253
PAIN L'f'UFRI, CIA 92291
USE OF PERMIT
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P E.2.E Sm, 1' t41:r .� hrfll .g YTS tf..C�:l d Ad E� ruTt�lsa s+'j .
A:LOAN BAR.}l YRS SHALL BF TH PLACE A T ME-'R:Xt 1i��13FC;1 iG�33.
?QUM,T,1PT ZN ,:if..%PJrE NOT 1W0L111:!a0
F1 OLjS.;a�? OR IPA�l�E3Stla.1�C 10
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3011.=1V
PIAN CHFICK M111 - 101 "CIE 01439"3 i a 1269,43
.
CONSTRUCTION 1ita: 101-OU0.4 I !3_000 44 1d.50
ME{;M4 1CA VEX -- P0IDL 01.0100.421-000
E1,7.M`['R CA1. 1-000420-000
PL1JMM Lid.. 1E31 -MV -419-000 7F,t►1t
D ,
APR 2 2 2003
iJ+, DUINTA � j .
CITY OF
DEPT. ,
- FINANCE e,
MAR laL'I,\',.4w,K,
n
.i`kCM
T vrAL PERAUT� n�..�IVS DUE NICYW.
A ,
$7794!3
RECEIPT
DATE
BY p
DATE INA D
INSPECTOR i
/f ;: '; - r 6-1.
t•' 1
3
. .
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
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
O
PLUMBING APPROVALS
Gas Test
Electric Final
7Z
-Waste Lines
Heater Final
Water Piping
Plumbing Final
_
s
Plumbing Top Out
Equipment Enclosure
+ Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Gas Piping
Encapsulation Ar
Gas Test
Appliances
Final
Q 31
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: