0311-059 (BLCK)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that'Ham 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
757720 C296 �� = AI/:112C
/Date Vim' Signature of Contractor -
f OWNER -BUILDER DECLARATION
-1
I hereby affirm under penalty of perjury tf at 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 sold'
compensation, will do the work, and the structure is not intend4or 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 EMP .-f I &SKS BM Policy No.
(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 wor ers' compensation provisions of�ection 3700 of the Labor
Code, I shall'fort ith comply with(those provisions.
Date: + "?Applicant/µ'�+-
Warning Fai ure to secure Wo rs Compensation coverage is unlawful and
shall subject an employer tgfcriminal 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, 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 propertyforinspection, rrposes.
.11
Signature (Owner/Agent)% � Z4 - Date////,
• BUILDING PERMIT PERMIT#
-
DATE VALUATION LOT TRACT
X 1 94,425.1 30357
JOB SITE
ADDRESS w .11?0'1V =0(K.t)t1nt..UJn, JeW C.
APN
772-2!%-011
OWNER
CONTRACTOR/DESIGNER/EN 1NEER
CC?Li. FST C7'i "02(3 iia%
JA!W5 F'3 OR MASONRY
74.9231..30VRl ' T,PYM Et 1Tr UC1I')''..2.2ZO
'18-990 BA1'"k1 ,32'-CI:.ME
PALMM"" M CA, X22 0
LA. Q Lxik4°.I A CA 92253
(7600)7'72.3036 CBIA 5713
USE OF PERMIT
�tl�a,��,�tA3;, F3iTII.I�II�Ci
'
100 LF 8' WALYJ32 V V '4VALU,501.P 4' W:Sf..11.lsKR ORCa'3 DY.TA.*L
KHD CDD APPROVED VED Ib'W48.2601 CDC*.
6 %P. WAIA, 100.00 L)?
3 .Ff. 'CStAM, 32.00 L -P
4 Ff. WAIr1 30,00 LF
ki5'£mm'13 CC3� GAF C;`0immuarlow
4,42SM
CONSTRUCTION FXF 101-000418-000 $7.2.00
D -Q
p� 10 2003
�.c CITY OF LA QUINTA
4 FINANCE DEPT.
MM- AT, C:011MI2T.TGP ON AND PI..r4.2d' CIM CK .
$72.00
LE, PRE, -PAW I=—
$0.00
TCCYIAX, 0KIRMT FJ RS ME NOW
$72.RU
RECEIPT
DATE! f`,�
BY
DATE FINALED
IN
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OPERATION j
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
OX to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wali Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
tees
Set Backs
lectric Bond
Footings
4Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
sinal
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
:Neste 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)
COM S:
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