0308-060 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
04 W Professionals Code, and my License is in full force and effect.
O co License # Lic. Class Exp. Date
P- LO
CC r- 72,3102 B 1110 990/04
o Z � ate ��/5 43 Signature of Contractor_X ! ��
cog.
J (-) coo OWNER -BUILDER DECLARATION
WLU I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) License Law for the following reason:
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, as owner of the property, am exclusively contracting with licensed
contractors to construct the -project (Sec. 7044, Business & Professionals
Code).
C'`) () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
O N
rn
CL Q WORKER'S COMPENSATION DECLARATION
o Cr I hereby affirm -under, penalty of perjury one of the following declarations:
U') O () 1 have and will maintain a certificate of consent to self -insure for workers'
i X W compensation, as provided for by Section 3700 of the Labor Code, for the
O _JQ performance of the work for which this permit is issued.
co Q O (c�,) I have and will maintain workers' compensation insurance, as required by
Q U Q Section 3700 of the Labor Code, for the performance of the work for which this
LO
Z permit is issued. My. workers' compensation iri'surance carrier & policy no. are:
oo � Carrier OUD R1�t'1J�I�IC IINISLI Policy No. MWC10134MM
r, d
Q (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/
,pate: A) �` 10 Applicant✓`W����%���'�%=
i `
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) �.'1- /.-� Date//r Z5 _
I
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 03WA-M TRACT
$138eQ-5.40 133 29323
JOB SITE
ADDRESS 434,98 C01M Did. OPO
APN
6096-380.023 ►
OWNER
CONTRACTOR/17 EN INFER
%"WAR.11.OAM9 OF CA1.I7�JI;L1+iIA
LRtMAft :f<<)MF--8 Off' C.A1.WOPNIA
78.401 C HIM-1WA''i 111
7 8-4 01 C WOHW.pY 111
LA QUINTA CA 92253
T—k Quum CA 92253
('760)77 7.0131 03L4 3434
USE OF PERMIT
SINk 3?�.� Y L1�tF�i:LIA1ti
S173� LOO, 11:� PLAN nc. NERVI;"1' NOES NOT INCLUDE B.LOC',K
WALIA POO): SP.A. 011 DRNWAY APPROACH. %% REDUC t IOW TO
PLAN CHE.CK,' FEE I?tli+:'1'f31� ULTIPf;'13ISSIJ.ANCir t3•P';�KME PLAN TYPE
TRACT CONSTR.Uv'1ION ;9",00 OF
PORCHPIPATIO • 45.00 SMY
GA.II.A.0EICARPORT 40,00 SP
1 I
'
FX31WPVF, F, SUM AAARY
COhiLy'I'RUCTION M E 101-000.41 B-000 i"m00
PLAN Cl ECIC FltE 101-000-439--318 $1:59.73
1AEC)•IMIClAf.1;i'E 101-000-421^000 &47¢00
ELECT IICALFEE 101-000.420-000 `121,41
15'(.L1Mr$r1gG FL?.g 101.000.419.000 $164.75
S3itC9NQ MOTION FPB > RMID 101-000-241-000 $13.84
L?t€6 i fl�ft117kE W]-001.423.000 *14.00
DEVR1.DFZR, IMPACT FEL
.KM -TOTAL COAT','f1R1T0.I`f0 AtM P1:.,AU CHECK
$3,706. Is
A-\ p TOTAL :!'KtsAMI MS DUE .iY0W
p
18
DEC 15 2003
V
CITY OF LA QUINTA
@ATE
BY i , j
D T �/
SPECTO
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
I INSPECTOR
BUILDING
APPROV
LS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
�
Return Air
1.77
Steel
Roof Deck
_
_ _
Combustion Air
Exhaust Fans
O.K. to Wrap
_
F.A.U.
_ _
Framing
,i
_
pressor
_
_
Insulation
Vents
Fireplace P.L.
Grills
.0
Fireplace T.O.
Fans & Controls
a
Party Wall Insulation
Condensate Unes
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
_}
Final
BLOCKWALL AP RO
AL
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVAL.
Gas Test
Electric Final
Waste Lines
Water Piping
-/
Heater Final
Plumbing Final
Plumbing Top Out
_
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Gas Piping
Encapsulation
Gas Test
✓�
Appliances
Final
COMMENTS:
-
Final
Utility Notice (Gas) v
ELECTRICAL APPR VA `
Temp. Power Pole
Underground Conduit OL
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service do
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)