0306-164 (PAT)LICENSED CONTRACTOR DECLARATION
N
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
cel W Professionals Code, and my License is in full force and effect.
O =) M License # Lic. Class Exp. Date
LLJ 14,M25
L 111,1131
tilZ't`
6 Z t --Date Signature of Contractor
—
co
O rr
r- U 0 ' OWNER -BUILDER DECLARATION
W W r- I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ 11 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).
cr) () I am exempt under Section , B&P.C. for this reason
u)
N Date Signature of Owner
ON
rn
Q WORKER'S COMPENSATION DECLARATION
D cc I hereby affirm under penalty of perjury one of the following declarations:
Lo O () 1 have and will maintain a certificate'of consent to self -insure for workers'
X w �: compensation, as provided for by Section 3700 of the Labor Code, for the
O � Q performance of the work for which this permit is issued.
m Q U (1,) 1 have and will maintain workers' compensation insurance, as required by
O0 Q Section 3700 of the Labor Code, for the performance of the work for which this
LO
Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier ` T. „`j`S' MAO Policy No. 042-COM019969
cb 5
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
3 subject to the workers' compensation provisions of Section_ 3700 of the Labor
Code, I shall forthwith comply with those provisions,,
Date: Applicant t '
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
• correct. I agree to comply With all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) Date / f
r.r
PERMIT #
BUILDING PERMIT
ONW- &I..
DATE/'. VALUATION a�yiz,+� LOT TRACT
JOB SITE
ADDRESS Tr1� f Y: r'�.-Tll�fz :.�
APN
OWNER
CONTRACTOR / DESIGNER / EN INEER
Ty, p>�
Ul 1t,13I;� UR.MRS'.ir3AJLJ�iiy 'J
1GYR1111.(:ONt�"�'rAX711014
? .•�j 2;Aeti�Ci�iU?�A It �1`.�.n sir
^t4 -442x1 t 43%11 LA
1,.AQU114T A C :2`53
1r01I,LM DESSMIT (V.L 92266
160)3f4 6i 6932 C %L 4 4517
USE OF PERMIT
t03 . r. Ut �IJVIN% !t.A aU (:L.:if .
PC 11CI i 11"AT.1 0 ± S.UA OF
]KIS CC:tom: U":i , OX7f T OF CQ.UIMI CIM11 111
'2,194.50
K'1t:£2:t&u.E F111.161.3MARY
PLAN,��!?� !?� RI K;1001419_31$ US,1 Q
k;U►`<a l2i Lr'•': d FiF 10 t -,"14 418--orAt $34.00
311 ON11 0 M0710111 PEE - IZ991D I, '11 -WO -241 -OW S. 50
e
nD
JUN 12 2003
CITY OF LA QUINTA
FINANCE DEPT.
SUB -TO:T,fcl..isOMILIM1,i,'°TOW 1z4MI•'Ue:+St�rff�:I�
J2 TIRE -r 43 i
U.r?t1
. 111011P.11. 7rya.e.l,•F.i.7. F 1"L ln" TAI -K HS!'±•Y
t^^.iJ�O`7Sl
RECEIPT
DATE
BY
DATE AL
INSPECTO
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
I
Underground Ducts
Forms 8 Footings
Ducts
Slab Grade
Return Air
Steel
7 --
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 Wali Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWAL 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 APPROVALS
Gas Test
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 Conduct
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: