0305-048 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
HChapter 9 (commencing with Section 7000) of Division 3 of the Business and
c14 W Professionals Code, and my License is in full force and effect.
O =) M License # Lic. Class Exp. Date
W
��I�Y7 B 11/3,0/0-1
f` r-
1
Z r- Date Signature Of Contractor—
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J U OWNER -BUILDER •DECLARATION
Ha I hereby affirm under penalty of peejury hat I am exempt from the Contractor's
U) License Law for the following reason:
Z ( ) 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 '
co () I am exempt -under Section , B&P.C. for this reason
LO
N Date Signature of Owner
O � f
Q WORKER'S COMPENSATION DECLARATION
IL
< Cc I hereby affirm, under penalty of perjury one of the following declarations:
FZp () 1 have and, will maintain a certificate of consent to self -insure for workers'
K W �: compensation, as provided for by Section 3700 of the Labor Code, for the
D J Q performance of the work for which this permit is issued.
n Q () (;) I have and will maintain workers' compensation insurance, as required by
(J Q Section 3700 of the Labor Code,, for the performance of the work for which this
L rn I— permit is issued. My workers' compensation insurance carrier & policy no. are:
Z Carrier ST.ATY, IFilt Policy No.
(This section need not be completed if the permit valuation is for $100.00 or less)..
k() 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
R 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 shgll forthwith comply with those provisions.„
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, indemn
& hold harmless the City of La Quinta, its officers, agents and employe
2. Any permit issued as a result of this application becomes null and voi
work is not commenced within 180 days from date of issuance of su
permit, or cessation of work for 180 days will subject permit to cancellati
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 buildi g
construction, and hereby authorize representatives of this City to enter up n:
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) ' Date -74 ,
BUILDING PERMIT PERMIT#
WWSAMS
DATE VALUATION $14151W1 ILI . LOT
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ADDRESS
APNIS�-:5
OWNER`'
CONTRACTOR t EENOIIN�EEjR.'f
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q/yDESIGNER
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USE OF PERMIT
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/FAY, T.&_I41ih1111 Mi;r DUE ? 0W
JUN 0 2 2003
CITY OF LA QUINTA .
FINANCE DEPT.
RECEIPT
DATE, ` .,
By /ft
' t f
D E ALE
[�
INS CTO
a'
INSPECTIOa RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
2
Ducts /
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
a
Exhaust Fans 10-00
O.K. to Wrap
F.A.U. 01
Framing
Compressor /
Insulation
,�
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines or
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
PO LS - SPAS
BLOCKWA
L APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVAL
Gas Test
Electric Final
Waste Lines'
Water Piping
_
Heater Final
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 r
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) 4 folpo. A 7�0�