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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
728107 1: HICd -3 9/30/04
Date �g 'y 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.
(DQ 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 01s7 P'ZI)0BL1C: IN UPolicy No. MWC100&w 400
(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 forthwjth comply wit t�o'se'provr'sions.
Date: �� '/� Applicant
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.
IMP64TANT Application is hereby made to the Director of Building and Safety
for a jpermit' 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
any permit issued as a result of this applicaton agrees to, & shall, indemn
& hold harmless the City of La Quinta, its officers, agents and employe
2. Any permit issued as a result of this application becomes null and voi
work is not commenced within 180 days from date of issuance of su
permit, or cessation of work for 180 days will subject permit to cancellati
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 buildi g
construction, and hereby authorize representatives of this City to enter up
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
$107.100.70 124 2f1323
JOB SITE APN
ADDRESS 434%7 € Ufr. . MV. C).RO
OWNER CONTRACTOR/DESIGNER/EN (NEER
LIMNAMHOWM OF CMMORNIA TINNAR HOMES O1"' CALWC?1: RYA
7c•-401 Cr 1MC1,MI TA,Y '111 78.4.01 C I-31GL AY l 11
Lt. QUgTI'A CA 92233 LA Q1C.3iNto CA 92253
( 60)77'7-0131 CMR, 3434
USE OF PERMIT
IMIGLE,1i,i•MII..Y .D V)MUNCI•
SFP - 1ZT 174, PLN 1C. PP"11 z DOSS NO'f INCLUDE BLOCK
WAL,"100iC SPA OR DR1TVEiN'.AV' A11`'f:OAZCH, 751/a fiEDUC;'1' ON TO
PLAN C H C.K FSE DUE TO MiJlu`f IPLE ISSUAWC F, 01? S.A3,4Z PL A14 '1":'2''x:
TRACT C'OZ+iOTRUCTION 11806/001 s1''
1 OR.CHlPATIO , 53.00 Sig
CA"ft_a1.�'33'?1(:ARPORT 4M.00 9F
MRI8d1A'ITEdi-'.� C,'OS-r 017 C:OM: 'i.°fC''ZiON
1?'�tlf a 1•i'1i'1s: �C7?l�C�.Y�
C'C3NTY12fiC"I'low .FEE
101-000.418.0110
$60.510
PLAN CHECK, N`E£
101-000439-318
$137:63
MEC HANICAL FE F,
101-000-421-000
$47.00
BI,WITPUCA1.1 FEE
101-000-420-000
$105,31
P1.tIMBINQ FEE
1.01.000.419-000
SM0.75
STRONG MOTION ME - RMD
101-000-2 31-000
$10.71
ORA.i 040 FEE
101,000-423.000
515.00
DEVELOPER IMPACY .FEE
51,4050
SUB.-ITOWL C'rJNIMCYCI ON ARO FII..ANq z ;t•19cftc
ba u
DEC 15 1003
CITY OF LA QUINTA Z
FINANCE DEPT.
RECEIPT DATE_ BY DAT yE I I rECTOR
107,1.f, 3y t0
$•3,128.80
$4.00
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
I INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
erground Ducts
Forms & Footings
Ducts
Slab Grade
_ _
V
Return Air
Steel
Combustion Air
Roof Deck
O.K. to Wrap
_ _ _
/ `� _
Exhaust Fans
F.A.U.
/
Framing
Insulation
Fireplace P.L.
Compressor
Vents
Grills
_still
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
Steel
_
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING AP ROVA ,S
Ak-A 00
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
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
_—
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: