0306-504 (SFD)LICENSED CONTRACTOR DECLARATION
I) 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
C4 w Professionals Code, and my License is in full force and effect.
O =) c) License # Lic. Class Exp. Date
r; CO U) Of,% 15316 i3 1:70/04
LUr-
i
.• _^
r- Z r- Date _ �' ' ' Signature of Contractor ✓ • 7 - 7•
O�. r �•--- �,.
J U C>"' OWNER -BUILDER DECLARATION
HLU I hereby affirm under penalty of perjury✓that I am exempt from the Contractor's
co 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).
( ) 1, 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.0 for this reason
LO
N Date Signature of Owner
O CJ
0)
d Q WORKER'S COMPENSATION DECLARATION
o Cc I hereby affirm under penalty of perjury one of the following declarations:
Lo FZ O () 1 have and will maintain a certificate of consent to self -insure for workers'
X w U- compensation, as provided for by Section 3700 ofkthe Labor Code, for the
O � Q performance of the work for which this permit is issued.
m Q () (\)'" I have and will maintain workers' compensation insurance, as required by
O 0 Q Section 3700 of the Labor Code, for the performance of the work for which this
rn f— permit is issued. My workers' compensation insurance carrier & policy no. are:
,It Z Carrier STATE FLIW ? Policy No. I' 6�1 14.03
Cb5
Q
J (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
3 subject to the workers' compensation provisions of Section 3700 o(rthe Labor
Code, I shall forthwith comply with those provisions.
Date: ' r r J 2 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
111111 of the Labor Code, interest and attorney's fees.
4 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) -•/ r ' r�.., �'� Date r
M�
BUILDING PERMIT PERMIT0#
5(
DATE VALUATION Cl&,K,342M LOT 43 TRACT Zr4 .t
JOB SITE CSC.°. .. � \iI�O
ADDRESS
APN W9.3 -WO -023
OWNER
CONTRACTOR / DESIGNER / EN (NEER
i.dy. Q1WTP..DL7NRA 450
'.:i )1.{I\MmTJ.olu %3FV.w-o1'own, two,
5005 C.AL•T.�E W.WU kE4k b"iM $I
: ")o'.. c-ul..1:'. 3,v,4 9`.ix":en
itia.M F3P'IMM :IP. 944,�
;i,-�:.3'vEi S�IZ1i�C�� C;: � y.2264
fT l9 2 - E3� C13110 686{ 1
USE OF PERMIT
••s'..RAVF3*
r3a,R: lhJ A. 14!• Sf.ct ilR V? CYt {JW&.r, 44 0113 4'-
��ia#.IaI�"y �C�Ji., ��'�'� �:?..�i�ILtitP.t�'�;1't.F'PfZ.f?A� 1•T � `;� s:.lb1}UC:"tr�'+Rd'1°s� E't.�?�'�i .
�;i?T�;f°K; t<'�f? 1i3tlF` � L"hf>iJLT%�I�� I��SLF.�.2JC.I� Ci? SAa�%�;. I�iw��1'I"YPN •
1 41 41STIMJCTi IO)q Z W ;3F
fTRACT
L'MCI �S?S�P�•:�C i�i'w� '' fie;+. tii� %l' r.
YIE31MAI 1W. COW OF C0.01SURDIM0. H
13644201
Cr.)NOT]R CTION Y',F% 101-0001.418-000 S`769M
I'LANCRF•4;`R; FEL ?t7s-i)fF33-�S�9••31fr' �t�i3.t�i
HISCI°F IICr21 T. Tlvl MUD
EI,WTR1- A1,; 1tF,
P MD.1�:4011y, 11MIS
41't$ONE," MD"CIEW1 F-8 - RESID 102-004-241-000 $13.o
`
ORAD 11101 FEE 101 -000 -423 -OW
0Z'UtsLOPIDR IMPACT ;rp�ir �?,tIGS..rrJ
+
�t,Yl�••�i�i�:"°,{,.-t�`.'.i Y raiJ?:�°iC'`�?>J .�1�X7 t�`i.:t3�,i1'C"•1:..F.�';�':
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VRE-:�=:r+.,IL? I ECS
50.00
VAUGL.W11
FKR" r FE , = tl"WE HOW
11 20031' ...
CITY OF LA QUINTA
FINANCE DEPT.
RECEIPT
DATE
BY
DA FI D_
SPECTOR
r
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
J
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
O.K. to Wrap
Exhaust Fans
F.A.U.
Framing
Insulation
N,41L
Compressor /
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
/
Drywall - Int. Lathof
Lj
Final
Final —
BLOCKWALL AP- PR VALS
POOLS --SP
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVA
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
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)Tj
ELECTRICAL APPR VALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final _
Utility Notice (Perm) V ��
COMMENTS:
v ` -