0305-114 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
I— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
(V W Professionals Code, and my License is in full force and effect.
O M License # Lic. Class Exp. Date
B 19C. 0W1,12C
oZ Date �� t ; �jSignature of Contractor v
J U 6-1 OWNER -BUILDER DECLARATION l
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
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).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
ce) () I am exempt under Section B&P.C. for this reason
LO
N Date Signature of Owner
O rn
d Q WORKER'S-C.OMPENSATION DECLARATION
o cr I hereby affirm under penalty of perjury one of the following declarations:
LO O ( ) I have and will maintain `a certificate of consent to self -insure for workers'
X W �= compensation, as provided for rby Section 3700 of the Labor Code, for the
m� Q performance of the work for which this permit is issued.
Q () (�� 1 have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
li L Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier TREPUBIC 1A DYMN1T' Policy No.
� 1$671601
co
�d
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
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply wit, those provisions.
Date:i r 7 Applicant
tr `.
Warning: Failure t secure Workers' Compensation Eco age is unlawful and
shall subject an employer to criminal peAalties and civil,finesLp 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
4 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) VASA A A— Date !
BUILDING PERMIT PERMIT# . :
0305-114
DATE VALUATION LOT .. TRACT
S165,244.70 27 29323.1
JOB SITECi
ADDRESS 74-00 COM, LMIA
APN
OWNER
CONTRACTOR / DESIGNER / ENGINEER
POADEROSA HO F. S H,, MO.
POWDER05A, HOWS R 1110;
6671 WPM DRIVE
400 S.1!ARRELX, DR, SUTIiM, B 103
PLEASAN ON CA
PALM SPR_WGS CA 92262
(703)187-710 (ML4 2346
USE OFyyPERMIT
�� � q*
ISIN :7UI 1rtYty 1 i D W i i L+NG
x1'D - L;OT PLAID 3'J PI DOES NOT 114CLUng B.L0C1a
wus, PooL, SP.A oR WwwAy A'PPRo Aca 7s% R1.,1"i17ma. ro PLAw
CHECK 1PEL L3UA TO Mi3L91PLF 1.".SUANCE OF SAME PLAN TYPE
r
TRACT CONST1+tiXTION 2,723,00 Sit
PORCMPATIO 323.005F
OAItAi iMAFt1''#3R'N 654.00 S.1•
Y.
ES�'Ai, Iff rpm 0091' Cr1{ CONSTd YC110NN
1155a44,70
PM r FEE 613114AURY
CONBTRUCTIO14 RE 101-000-416-000 070,50
PLAM CHECK FKF 101-000439-318 $180.69
ARV411ANICAL FRR 101.000^421.000 $92.00
E1:.FX'1'RI.0 AJ, FFY , 101-00G-420-000 $142.06
ELUNINNOala l0�X000•4Y �OOi1 �It17.23
STRO110 MOT!ON FEE p RE!51D 101-000-2+41. -000 $16.53
(TRADING FEE? 101.00IO-423.000 515.04
1. EVE-LOPER IMPACT FEI Z $2,405.01
SUB -TOTAL COM nk-UC'1 011 AND PI" Cs3RC'K.
$3,18A9,02
1;MV PRR.: PAS) F
$0.00
D °
A1a PE.M 11"EMS DUE NOW
JUN 0 6 2003
CITY OF LA QUINTA
FI
RECEIPT
BY
DATE FI FED' SPE OR
J
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing = /,
Compressor
Insulation 411$, o
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath — 3
Drywall - Int. Lath
IV
Final
jod-
Final
BLOCKW LL 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 APP VA L
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
Gas Piping
Encapsulation
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL PPROVALS
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)
COMMENTS: