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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
)11128107. B 111C ('2 MOM'
Date r ' !� ' 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.
( P)A 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 OL -1.) REPUBLIC 191$4) Policy No. h9WC1,0M43400
(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 withethose provisions.
Date /*'.! lJ� Applicant/L��:/
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 applicatbn agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and empl
2. Any permit issued as a result of this application becomes null andrin
work is not commenced within 180 days from date of issuance o
permit, or cessation of work for 180 days will subject permit to cance
I certify that I have read this application and state that the above inform
correct. I agree to comply with all City, and State laws relating to the bconstruction, and hereby authorize representatives of this City to ente
the above-mentioned property for inspection purposes.
X
I� Signature (Owner/Agent) ll/l/,r Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT. TRACT
$136,3412,W 135 29323
JOB SITE
ADDRESS 43-W COREE DFL ORO
APN
609-380-023
OWNER
CONTRACTOR/DESIGNER/ENGINEER
L?NH� 110hE.S OF C:AI-.II —WiA
L;Me dAR ROMES OF C?,'L i"01MEA
78-401 C MGI WAY 111
781 401 C l:itC'r1:'TMAY 111
LA CYi%iJi1TA CIS 92253%
LA QUWTA CA 92253
(76-gV-17-0131 CB1.43 3434
USE OF PERMIT
a�Ik�OLE, FAMLY D i ?t 9 101
M0 � IDT 17.5, PLAN 2V5. PEP.MJT DOES NOT INCLUDE BLOCK
WALL, P006 SPA OR DRIVEWAY APPROACH. 15%I EDUC:TION TO
PLAN CKWE.CK ".9 DUE TO MULTIPLE ISSU.ANCH, OF SAME PL&N "TYPE
TRACT MRSTRUC:TY01N ZIU9.90 SIA
`e'dPS'1'1%PATIO ' 45.00 Sig'
C�.,raltA.C1I�C:P��'E:1'C�11T 49S,0D P
M'Lll TED cote ' OF CIQN4441MMMON
11.2`W4711X)
. Effl .'r ME ' 0MMARY
CONSTRUCTION FEE 101-000.418.000 V749.00
PLAN CHV,'K 1; 101-000-439-319 $1513.07
MC1•IANIr—AL PF -19 1101400-421-000 $47.00
,
ELEXT121C:A L i=ELY 101-000-420-000 $ 124.08
PI.JYMBINC1FEE 301.000-419.000 $150.73
STRONG MOTION PEE , ",SID 101-000-241-000 x1:3.63
ORATHOx!t E 101.000.423.000
DEVELOPER IMRACPT IME. $2,405.00
SUB- IrTAL C:0WMIX110.9 MD PLM C° UMr,
$3,690.53
3;.BM P139+r1'AID FEERS
$0,00
Q DC7(AY3 P1M- 2'.I' FEVEiS DUE NC1W,•
DEC 15 2003
/
ITY OF LA QUINTA V
113EP-1
9r,
+. . BY DAT ALE IN
�s� �`.��'n
PECT
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVA S
MECHANICAL APPROVALS
Set Backs
IF
Underground Ducts
Forms & Footings
_
Ducts _
Slab Grade
Retum Air
Steel
_
_
Combustion Air
Roof Deck
13 O
Exhaust Fans
O.K. to Wrap
F.A.U. 1 /
Framing
_
Compressor I /
Insulation
/
ents i
Fireplace P.L.
Grills i q
Fireplace T.O.
Fans & Controls
Party Wall Insulation
_
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - IM. Lath
_
`I
/001
v
Final
Final
POOLS - SPAS
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 I
PLUMBING APPROV S
Gas Test i
Electric Final I
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
a
Encapsulation
Gas Piping
— - —
Gas Test
Appliances
70
Final i
COMMENTS:
Final
Poll;
Utility Notice (Gas)
ELECTRICAL APPROVAL
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
1
Sub Panels
Exterior Receptacles
y
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
44IL—L
Utility Notice (Perm)
A�
I I