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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
Professiollials`e&d , and my License is in full force and effect.
License # Lic. Class N Exp. Date
itt� X45 fi: �;
-
Date ISig nature of Contra
OWNER -BUILDER
I hereby affirm under penalty of perjury that',l, aeexempt 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 Policy No.
RX, .E'IvlPT .�.
(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 subjectrto the
workers' compensation laws of California, and agree that if I should ,become
subject to the workers' compehsation provision of Section 37010 of ^ e Labor
Code, Irsball fo hwith comply with those provisi ns.(i1t' p
Date: t dpi` , ADDlicant `, ,.,._ rd tr i" � .A
Warri'i'W.'Fai4ure to secure Workers'{Co ,,penrsation covel'age is unlaWul
shall subject an employer to criminal pe alties and civil fines up to $100,000
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 is
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, ' demnify
& 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 canc`;Ilation.
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 rglating to the building
construction, and hereby authorize representatives of his/City to enter upon
the above mentioned propertyfor inspection
Signature (Owner/Agent] "� �, -� 1# `* �,e' Date 1
BUILDING PERMIT
PERM T#
DATE VALUATION LOT
TRACT -
ty�'
3.
JOB SITE F.
APN
ADDRESS
79-Xia C"..AMWO. ORADA
OWNER
CONTRACTOR/DESIGNER/EN INEER
7 9. 230 CMft4'0 ROSATM
62.762 CHMI�?�?-a�, ONAVI&
TA QUA A.
I"3. s. 10 CA 92255
(760)2,75-6403 Cuto 1604
USE OF PERMIT
YL
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PCJ4'31A P-A...03.1.AMSISs4lE:Rd'VIS a'HAL1.. 01:' 'J*N
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C-01onud7mm.tq
PS,tr7N P fl SCK 1"/iriv 101-000-439-336
$99.45
Ct:}'NSTR.UCT10H YETY, 101-000-418-000
$153.00
1@AECHANICA1., FER -!, F -00L 101.000 -421 -ow
SAN
E1[XCT'P.%C,l'r.I., 11UR .. -000-42(�'000
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MA
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AUG 13 2002
CITY OF LA QUINTA
FINANCE DEPT.
%1• ik-VIAL C O)ATIRUC°-nom.AND
PLOT T Me=
MISS P, " -P ERF3
$348,45
$0 100
RECEIPT
DATE d
b./
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
L BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
,lab 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 8 Controls
Party Wail Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
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
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
Pool Cover
Encapsulation
_
q
Gas Pipingd
Gas Test
Appliances
Final
COMMENTS:
Final
Utility P' Mice (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)