0305-260 (SFD)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
7010.3F1
Dade ��' ..;... ^ ..•—�-"_,..w.-�...._.__ �,�'�:_ _. "•�e�:' � ... �._.
Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt fromtContractor's
License Law for the following reason: _ �' \
( ) I, as owner of the property, or myemployeeswith 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.
(k) 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:
Cartier 13"UM FUND Policy No. P0,04f��kS,t�►1Z
(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 Secii6n.3700 of the Labor
Code, I shall forthwith comply with those.pons
ovisiL --
.�Date: '"•'� �'� Applicant i "':";%�::,�.• :� .,._..—a.._„r�_° .
/ .. _.
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penaltiesiand civil fines up,to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees. �w
IMPORTANT Application is hereby made to the Director of Building and.Safety
for a permit subject to the conditions and restrictions set forth on hi
application.
1. Each person upon whose behalf this application is made & each person a
whose request and for whose benefit work is performed under or pursuant t
any permit issued as a result of this applicator agrees to, & shall, indemni
& hold harmless the City of La Quinta, its officers, agents and employees
2. Any permit issued as a result of this application becomes null and void i
work is not commenced within 180 days from date of issuance of suc
permit or cessation of work for 180 da s will sub'ect ermit to cancellation
PERMIT #
BUILDING PERMIT
DATE VALUATION iF� 2..i�� LOT �$ TRACTJOB SITE 2'a+(t./3'•1
ADDRESS 49- >i�:�e'.gt�N G.;"»f3+:fZ',�Fk, ' APN
OWNER CONTRACTOR/DESIGNER/EN (NEER
(�{�t'y�'[;yr{W��6e'�1
9r'3.°R d.a..kLl. '`� �111.Gi. 4: 3.t Rg�..4:,. 1 t.)& 9968 .'63.tC1TFRT ff-F N31.7:.. : Vb .
CWT T 3 3, O C S7's 1 3 1 SAM TAW. 0 Com', 92131
.. (�3t3yi'i5if��At9:� �� �r���•
USE OF PERMIT
e.! A 71, • l.A.? D 4Ah .l' L.dA C�i .7.v lA n. if S.F'�i'lai p i✓t.�L'nJ AN... 4 tkN
��,{'9LLS, P0014 �tfyA� rrlb �}%�� r���'rY.d�'� APPROACH
r4edrl�.Cn's,+!T tC1+�+'G6� Ell ff"O'� �$.Rlf (tV ca�F'
,Y1�+{�V .�>135, 0r0o .l. l'
qRIV
"C. '�t�TKE) COST Off' CS)NM��:t{`T��., S
\E..;�
c:.,C)N.�v"1'Ri7.��F.101: F2i n
a0'1•��t1-� i8-000
002,00
r>LAX CHECK tr E
? .?.l �cai3t�Mt;iS�-31 �
s i<4.3
MSACIIANICAL FM
101-000-421-000
3 11. S. !_1 A
ul ':s: i! WC t.L ir?%
)01-000-420-000
iiI'lil'.IV
F,L 3 PIM0PKIF
'A0,-000.419.000
IWA.��
Ib-10VIDN i";tt.' - FUNZ ED
r.01-0Ot -24.11- ?0
$�7.ii.
�:i�`?.c�:1�i� 0 FFF
101 -000-423 .0013
5115.0
7.°I?�VE�.l?PER BQaDi`'1�.(°'.Y 1''f•',i:
s7".75,09
P14.1 I}EP0.11`]'
t ti 1 r(3Ui1�43�•31 3
SM, 09
Y 1 p
ra
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.
RECEIPT
Signature (Owner/Agent) � j�-- � Date t/ f
Y ✓ '
AND PIAN
_PAU) F11
T er)TP1, P.7IMUT ,e! �;i9:'S :iJY :kAAN
DATE 19Y � •�
174,975.20
$45122.64
• 710,00
JUN 0 2 2003 .
CITY OF LA QUINTA ,
FINANCE DEPT.
Y 1 p
ra
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.
RECEIPT
Signature (Owner/Agent) � j�-- � Date t/ f
Y ✓ '
AND PIAN
_PAU) F11
T er)TP1, P.7IMUT ,e! �;i9:'S :iJY :kAAN
DATE 19Y � •�
174,975.20
$45122.64
• 710,00
k - -
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
- - 3
Ducts
Slab Grade
3 47
Return Air
Steel
- 311015
Combustion Air /01
Roof Deck
--1'>- 3
Exhaust Fans
OX to Wrap
- —
_
F.A.U.
Framing
_
_
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
l
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final - -- y—
Final
BLOCKWAI L APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
-/ -3
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
Bim'
Appliances
Final
Final
Utility Notice (Gas) vu
. 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,(Pe )
COMMENTS: