0306-315 (SFD)LICENSED CONTRACTOR DECLARATION
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
W Professionals Code, and my License is in full force and effect.
O M. License # Lic. Class /�, Exp. Date
Y1 W.30/013
Z • ; ` 'Oatei.lr' � � ' Signature of Contr ctor
J U s OWNER -BUILDER DECLARATION
W UJ I hereby;affirm under penalty of perjury that I am exempt from the Contractor's
U) 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).
( ) l; 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
r, N 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 foP 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 1,41,AMNA1,11'tui.ION 7 Policy No. 130YSA119
(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 Pmploy 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 th`e workers' compensation-p`rovisionsf;ff Section 3700 of the Labor
Code, i shaliferthwith comply w�t'h those provisions:-�---"—
f'Date: 0.� �. Applicant��
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $1'0QQ-OD- , I� %e
addition to the cost of compensation, damages as provided for in Seeti . n 3706 (r
of the Labor Code, interest and attorney's fees. U
IMPORTANT Application is hereby made to the'Director of Building andEhN
for a permit subject to the conditions and restrictions set fo h
application.
1. Each person upon whose behalf this application is made & eac , persongtr
IN
whose request and for whose benefit work is performed under or .uisuanWeF—
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 withlall City, and State laws relating to the building
construction, and hereby aufthonze representatives of this City to enter upon
the above -me ntibned'prope�rty'for inspection purposes.
.,.,.Signature(Owne /Ag ent) Date
BUILDING PERMIT PERMITTa�J
DATE VALUATION $141',30,11tf LOT ,11,41- ` TRACT 30023
JOB SITE
ADDRESS $1^�.F.aVi Tr}L�tr
APN
OWNER
CONTRACTOR / DESIGNER / ENGINEER
SHEA LA �F'•J;'11"� ='A_, LLC
S,IWA kfi0 M B'S
�i0"31 ? 2':�di i�L7�,r I�14i�rxr
X31 •:1 ME 62
LAQY.,t'A1i;A CA. 921253
L.A t.ZT.iWA, L„(!,. .9288.1
.W16
USE OF PERMIT
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10,303,70
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soPL.AV
1".HH.C9. P_111'- Y C2 sl(LC•43 -3 f.8 $139.19
1+ i�C H:A<'3f4l11. ;1; 101-OGO.42E 1000 $73.56
L'.;pc;TRICA,LFEY,
P.11 YNDiAric"11;'#?'R 1tf>(�t�;1Qt>�Yg QGIi £1'b6,^1",
Si1' ..?'N A10 1G NKI-1Zr-MLSID 101-000-241-000
tUt�10�i-4,23.,000
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26 2003
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TOTAL DM -NOW
RECEIPT
DATE
BY
NSPECTo
L
i
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
Framing
F.A.U.
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulaticn
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL PP OVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines C - -
Neater 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
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground ConduR
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power, u /
Final
Utility Notice (Perm)