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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
Date Signature ofContractA/,�--''"'_.S"
1-1
OWNER-BUILDEWDECLARATION
Ir
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).
( ) 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:
Carrier STA 303ND Policy No. 1XIM&M2,4a•f5?
(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 thps provisions;
Date: 5' 22 •0 Applicant = r. "w-
Warning: Failure to secure Worke s' Compensation coverage is unlawful and
shall subject an employer to crj inal 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, 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
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) j r ' �" �o-� ',Date,
BUILDING PERMIT PERMIT#
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DATE f% ' rVALUATION LOT rTRACTJOB
SITE
ADDRESS Fitw� 'i'�� Il+�iE �% i Y .
APN 61M.3 8G"fKA.`
OWNER
CONTRACTOR
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(/`DESIGNER
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PPLM, ra'!?RT10S CA 92:264
PALWVRiNGM CA 92264
USE OF PERMIT
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LEM
TIMID
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JUN` 0 2 2003
CITY OF ~
NCE IDW..
BY a ; V
DAT I7
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
Bond Beam
BUILDING
APPROVALS
MECHANICAL APPROVALS
Sewer Lateral Pool Cover
Set Backs
Sewer Connection Encapsulation
Underground Ducts
Final
Forms & Footings
AD Z Z2Q
Ducts
Final
Slab Grade
COMMENTS:
Return Air
Final
Steel
Utility Notice (Gas)
Combustion Air
ELECTRICAL APPROVALS
Roof Deck
Temp. Power Pole
Exhaust Fans
Underground Conduit
O.K to Wrap
Rough Wiring
F.A.U.
Low Voltage Wiring
Framing
- , p S _
_01
Compressor
Main Service
Insulation
/
_
Vents
Exterior Receptacles
Fireplace P.L.
G.F.I.
Grills
Smoke Detectors
Fireplace T.O.
Temp. Use of Power
Fans & Controls
Final / "
Party Wall Insulation
Utility Notice (Perm)
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall -.Int. Lath
POOLS - SPAS
BLOCKWALL APPROVALS/
Steel
Set Backs
Electric Bond
Footings.
Main Drain
Bond Beam
Approval to Cover
Shower Pans O.K for Finish Plaster
Equipment Location
Sewer Lateral Pool Cover
Underground Electric
Sewer Connection Encapsulation
Underground Plbg. Test
Final
Gas Piping
PLUMBINGPP50VALS 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)