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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
752M. 7B HIC. OM' 1/2(
Date I �ySignature of Contractor ���� ��� ✓�ad
OWNER -BUILDER DECLtARATION
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.
(,)/,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 Rrip is INDE1d1NIT' Policy No. 15671601
(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.
ate: II plApplicant' ` -�' Z, --s ,<^� ,
Warning: Eallure to secure Workers Compensat1on)coverage is unlawful and
shall subject an employer to criminal penIties 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) r �� lr�l Date If1 ,
IS, Ul/ I v i v
BUILDING PERMIT PERMITk
--'' `-
IO -112
DATE VALUATION LOT ZS _TRACT
$172„AWI.10 2!)323.1
r r
JOB SITE
ADDRESS 79-645 CO Y n�i FA
APN ���� 5• �D��
OWNER
CONTRACTOR / DESIGNER / EN (NEER
POAiI MOSA 1103v£W,,� 71, INC.
F. 014DIM019A HOME 111NC
PALM S'PT IGS CA 92262,
(703)MY-710('1't.E 234.6
USE OF PERMIT
N1�0 • LOT 35, PLAN 2C XL PLAN LOIS NOT INCLUDE BLOCK
WALLA P00I4 0SPA OR DRIV:RIVAiA.PPROr' CH
J
TRACT CONSTRUCTION %3313,00 SF
POIRCH/PATIO -: 3117.00 SK
C1AI'.t�'►C1I81C; l�I�i?'C) .IT 671,06 6F
A
ESTTMM COST OF C; NSMUl?•.1^10,N'
i^,.2d4U'1.2iD
P MTt' : sula f R
COANSTRUCTIONFEL 101-000,418.000 $893,03
PLAN CHECK FZZ 1011-4100-4:39-318 M.s6
MECHANICAL FEE 101.000-421.000 $105,00
'
ELECTRICAL TW, 101-000-420-000 $146,25
'
I•'ll"tYta BINO ME. 101-000-41,9-000 $16840
S`I'ROWOMOTION FEE,- RESI:) 101-000-241.000 $17.2A
4YRAilINGF E 101y(i06.�•�t23}O00 $I�.8f3
1 EV?LOPRR IMPACT I,E V,405. CIO
.
8-�-TOTA1'. COIvTMUC1`iON AND !?3,AN CRECK
$4,406.8.5
IMS PRE -PAM FM9
$0.00
D e DUE
WAL PXHWT MESS AOW
54,496.85
JUN 06 2003.
CITYOF.LAQUINTA 4`>.
FIMaNCE
•
RECEIPT
DATE
BY
DAWINAItXDWr9PECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Roof Deck
Combustion Air
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
i (��
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
-05 az
Final
Final
BLOCKWA
L AP ROVAL
PO S - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBINGPPRIn VALS
Gas rest
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
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
;