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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
B MIC
Date, y— Kd :1 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 propef3y, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code). . , r
( ) I am exempt under. Section r 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 OLD REPIIbLIC IND!) Policy No. ?JdWC100 04+0Lt
(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 wit3hoserprovisions!
DateIle r Applicant // :%r1T!��`�
r .r r
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) Date /11- i`j '• +
BUILDING PERMIT PERMIT#
DATE .7 VALUATION d LOT 125 &r TRACT 141931221. V/
ZZ
JOB SITE ADDRESS Li.�«Yfl.t CO r.";; -VEL ORO APN
OWNER CONTRACTOR / DESIGNER / EN &NEER
Ll"t ll, HOME." OF C.ALWORNU, 1rENNA.R HO1 VINS OF =.3 W". Lll.
78x402 C:MK:xNth7hY I I 1 78-402 CHICYI- 9 AY I I I
L&QUINTA. CA 9.2253 L&Q012-IrrA CA 92253
(760)777-0131 CPU, 3434
USE OF PERMIT
SM - LOT L 25; ,PL AN 3A. PERMIT DOES NOT INCLUDE BLOCK
'v4ALM k1004, SPA OR DWf EWA,Y APPROACH, 750A REDUCTION TO MAN
C HECK f'EU DUE TO MU.I T IPLF 5?1.01JUP,'Nf E OP ,RAMS, PLA14 TYPE
TRACT CONSTRUCTION 2121.00 SF
P6P,cWPAT10 45.00 SF
Q -4J ~ANUC.AR.PORT 447.00'4F
EWIDUTFID COU OF, COMMUCUOR
CQN18TRUCTIONFEE
101-000-418.000
J.tlf?
PI.f;N CkIr�' K F LIZ
101-000-43119-318
$149,35
MEC:HMIC.,A,?. ME
10I-000-421.000
WOO
ELECTRICAL Me
10 1 -000-420-000
$116.69
PLUNA 31NOIM
101.000.419000
$146; S
w'L'IdONO MOTION nE - A2. ID
101-000-241-000
f}ii"Wo FER
101.000.423.000
$19.00
DENT 'LOPM IMPACT ME,
$Aosm
SUD-tMAL CON "S t071101J ANI) PLAW Cilt+ M,
LMU 1'01 °t.+L S1.E.idSLY.L89. 'L��.4wES DOk NOW
DEC .15 2003
CITY OF LA QUINTA
FINANCE
BY DA NAL V I INSPICTOR
124,5300)
$3,619.23
$0.00
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVAI S
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Slab Grade
Ducts
Return Air
�1—
-
Steel�7I
Combustion Air
Roof Deck ✓ -
O.K to Wrap /�
Exhaust Fans
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
Finales _
BLOCKWALL APPROVALS
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 APOROV I S
Gas Test
Electric Final
Waste Lines /_
Heater Final
_
Water Piping _ -
Plumbing Top Out
Plumbing Final
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) �l
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduft
_
Rough Wiring -1
Low Voltage Wiring
Fbdures /
Main Service
Sub Panels
_
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final _
Utility Notice (Perm)
1