0303-294 (BLCK)LICENSED CONTRACTOR DECLARATION PERMIT#
U) I hereby affirm under penalty of perjury that I am licensed under provisions of BUILDING PERMIT 03W.3-2'9 4
F- Chapter 9 (commencing with Section 7000) of Division 3 of the Business and DATE VALUATION
U) $3,!5,15,W LOT its - TRACT 30023-
04 LV Professionals Code, and my License is in full force and effect.
O ch License # Lic. Class Exp Date
d (MG934 , B fi Q/Q3 JOB SITE IADDRESS 61E-73511 MM-98 UG4:iL,tiNE APN _
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Z � Date ! d �.3� Signature ofgontrac�t0 ��i•h i •' �`��il� „�,, OWNER CONTRACTOR/DESIGNER/EN INEER
t` f— o OWNER-BUILDER DECLARATION MK& 1101"S SMA, 1_10WX
_J U Z 81-7,60 AVM M 62 81-260 AVS 62
LULU I hereby affirm under penalty of perjury that I am exempt from the Contractor's LAQXTNTA CA 92253 IMM AL. CA 9218$3
n.
U) License Law for the following reason: (909)833-6996 MR 6876
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 USE OF PERMIT
( ) I, as owner of the property, am exclusively contracting with licensed/ MURAL 33LTMMIG
contractors to construct the project (Sec. 7044, Business & Professionals.
Code). iK1 tt, 0=eo a I .x t vs ~i11C �.Vta sT6R YtF F. V Ca/ 8 tcJ
ce) () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
O0)
Q WORKER'S COMPENSATION DECLARATIONEL Z
_I p 1 hereby affirm under penalty of perjury one of the following declarations:%a. 3�3,�� p, "HT=.
Lo H O O 1 have and will maintain a certificate of consent to self-insure for workers'
X w compensation, as provided for by Section 3700 of the Labor Code, for the
m �
Q performance of the work for which this permit is issued.
Q () (���) I have and will maintain workers' compensation insurance, as required by
O Q Q See on 3700 of the Labor Code, for the performance of the work for which this
11 0Z permit is issued. My workers' compensation insurance carrier & policy,no. are:
Carrier ZvA7'I �idllk. 4Jl')F l� Id Policy No. Y�g530S+ Eb"1�N>Gt%?i�TD Coss Off' C�iI`7,'t"�'Ift'iDA;'�SCi?�: )_s?'� ,0o
C3 PM. M PER SUAMARY
J06 5
(This section need not be completed if the permit valuation is for $100.00 or less). COI�l3�"T UCTION' FEE 1X11.000 41'0.003
X63,00
() I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any manner so as to becomeisubject to the
workers' compensation laws of California, and agree that if I should become
V.— It ..
3 subject to the workers' compensation provisions of Section 3700 of the Labor
Code, i shall-forthwith comply with thosei0rovisions. I
oQate ' '° K!1" ,,-. Annlioant,/' I[i..r`$PJ
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 APR 0 3 2003
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees. CITY OF LA QUINTA
IMPORTANT Application is hereby made to the Director of Building and Safety FINANCE DEPT.
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 M-D-'�'�Gf' AL CONST �.�,Tf.'°i ON'f{'t� D PLAN C�FL�C:' , $63.00
whose request and for whose benefit work is performed under or pursuant to g,�LS' k"'fi-PALLS F;1 QQ
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 TOTAL 3'N,.�1: MES DUE NOW
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.
� p RECEIPT DATE, BY E FII LED I R
Signature\(OwnerA)geli't)!`1'�1�� �Yra.� Date -'`' Wil. !,' ,, fes': -COY
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
POOLS - SPAS
Steel
Set Backs
Electric Bond .
Footings
Main Drain J
Bond Beam 0j
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
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
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole'
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub•Panets
Exterior Receptacles
G.F.-I.
Smoke Detectors .
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: