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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
728102 B Inc 7 9130/'04
3 Signature of Contractor
OWNER -BUILDER DECLARATION
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
S4,'tion 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:
CarrierQLD REi'1?f3°I,.1C I' SU Policy No. WC100213400
(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 -those/ provisions..
,1Date: P`/i, `�'S Applicant +C > fel et .��l[`u✓!�
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, 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
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)/Z�s�'�r ' Date L`� `7Vii'
BUILDING PERMIT PERMIT# 40
DATE VALUATION LOT 03DP-W TRACT
29323
JOB SITE APN
ADDRESS 43-4.9.1. C:O.D :C^'�: I'ltz"L, OROt'0,,.+w3
OWNER CONTRACTOR / DESIGNER / ENGINEER
L.1:;1;i1.+1". HOMO OF L .ALCM" (A
78.401 C Ii GHWAY I I I
I -A. Q UINTA, CA
USE OF PERMIT
MCUP, FA2,U.,Y DWEL-1-MG
LE WAR HO NE- S OF CALWOPNM
78.40) C I-TIGINT.AW 111
92233 LA QUINTA C.k 922.33
(180)777.0131 CM14i 3434
51110 - LOT 1A P?.A7q 4.€>,. PERMIT DOES'NOT MCLUDE ftf .)CK
WALIA P0014 SPA OR DRNEWAY APPROACH. I. 16% WEDUC;I H TO
PLA14 C:33ZCK,nE DUE TO PAUX. rlPLE IsSUANC''E OF SAME PLAN TIM
TRACT CONSTRUCTION 2122SIOD 40F
PORCtSi .A"O 53.00.SF
0AR.A.QWCA RPORT 425.00 SDS
11i4rMA'711i CO.rr Off' COMMUC<T.IOx
tF'tz'",(�WT' b JIM au11/f, URY
CONSTRUCTION FEL
101.-000-41.8.000
SW4150
PL -AN C:1'1fa'CK PHF,
101-000-439-318
$152.69
MECHANICAL PEP
101-000.421.000
7.00
F.I.I:-TRIC:.AL179Z
101,.000-420-000
$114.99
PD,iIM9TH0. T"ElE
'101.000.419.000
SH6.75
STPONO M OT1014 FEE - RESID
101-000-241-000
$12.99
GRADrr4Gs+'LF
101.-000„423.000
Sts0
1 71V'E1ZPER'IMPACT iti�.`:1:
$7,405.00
ATD'T -Ta.C.73i. Oa+t,Mi. 3"UfrTT0i4 AND PLAN °wDFZX
LEW PRZ-PAU) ITZ3
129052.40
$3,643.80
${3,00
p w D ITOTATI P 1TEES DUE NOW $13164313o
DEC 15 2003
CITY OF LA QUINTA 1
FINANCE DEel.
RECEIPT DATE BY DAT NAL ECTOR
i
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS__
MECHANICAL APPROVALS
Set Backs
UR ,ground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
_
Combustion Air
Roof Deck
,� _ _
Exhaust Fans
O.K. to Wrap
F.A.U.
41_
Framing
✓
Compressor
Insulation
Fireplace P.L.
_ _
Vents
Grills
_
_
Z
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
L42 71 Tig
Final ,
POOLS - S AS
BLOCKWALL 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 APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
i
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 APR VALS
Temp. Power Pole
Underground Conduit
Rough Wiring
✓
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
v
Exterior Receptacles%
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
.�