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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
606436 B 114,0!0'
,,,Date �?�� x ' 0 5Signature of Contractor P
OWNER -BUILDER` DECLARATION
I hereby affirm under penalty of perjury4hat 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.
Se( y) I have and will maintain workers' compensation insurance, as required by
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:
Carrier VAT E MID Policy No. f 71Dg!^ 1.43
(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.
.D to e: r� % 4 Applicant'�--�'-
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to cr rVinal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemni D
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes. f
Signature (Owner/Agent) .� * --� '.. Date E '
Al
BUILDING PERMIT PERMIT
05W403
DATE VALUATION �b 6 "�.$,31, 2 70 LOT' 121 TRACT � �3 R`•t . It
JOB SITj
ADDRESS 43-489 COM.'111% $JR0
APN ,00,.380-023
OWNER
CONTRACTOR/DESIGNER/ENGINEER
1.: A.QtilgfAA3'LIM-9 50
a °!0 W XJ.*.J L)ENE ,t.3A FAS, I C.
105 CA:f E APil:I•'M, FT kq; i.31
5005 C!%l'.::MPAWMV ,:w B's
'Psum CA,
.71ALIA ORMW CA. 927.64
C.(A* 6157
USE OF PERMIT
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"ILAN CEiFC' "ISE DWI, To! -41:101i, Pwax
01ONS HUC TIO KN: 101.300418.000 Malo
PLAN Cliscy, I21 zrg-OOuw4 f4�-311 �,�t.:�s
MECi• M41CAY,FEE 101•000-4123.000 S53,30 .
Ei f?.t:9 RIC-flt. FLEE 101-0001-4-1,10-000 $12q.89
I,►,1�A 3;r�iC? F ?E dt)1.0f1 - 19-di3(? $164, f,1
"fi4t.0140 MOTION M • RESI j) 101-000-241 •d14It3 51
x F�?1r 1X0 FZt- 10), W-00
i%1:°i) �J1�3!•it 111 PACT IFFY,: g�,405.G1
€iTlS•,_ i �:�:;>'r$l°c1UC"11: ?� , Ti PLAN Ctrs. 33048.03
A&W PREPAID T� $0.00
'A'ir"AT.:%''1M?W ' M'9'Dut Z�iC�W 53,746.002003
;FINANCE
CQUINTA
DEPT.
RECEIPT
DATE,
BYl J,
I PECTOR
! 6
,�
INSPECTION RECORD
OPERATION
DATE
INSPECTOR OPERATION
DATE
INSPECTOR
BUILDING APPROVALS MECHANICAL APPROVALS
Set Backs Underground Ducts
Forms & Footings // -- 3 Ducts
Slab Grade Return Air
Steel—j, Combustion Air.40
Roof Deck ✓ Exhaust Fans
OX to Wrap ✓ F.A.U. .do 00
Framing Compressor
Insulation Vents /
Fireplace P.L. Grills
Fireplace T.O. Fans & Controls
Party Wall Insulation Condensate Lines
Party Wall Firewall
Exterior Lath
Dryvwall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOL - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground iPlbg. Test
Final
Gas Piping
PLUMBING APPROVAL
Gas Test
Electric Final
_
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
I Equipment Enclosure
Shower PansO.K
for Finish Plaster
Sewer Lateral
t Pool Cover
Sewer Connection /
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final .
Utility Notice (Gas) AU
ELECTRICAL APPRO AL
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service _
Sub Panels 40
Exterior Receptacles
G.F.I. 10
Smoke Detectors
Temp. Use of Power
Final
_
Utility Notice (Perm)