0303-070 (CONR)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 r^, Exp. Date
/DateF ��';A" Signature of Contractor f'• '
OWNER -BUILDER DECLARATION
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 pezempt under Section B&P.C. for this reason
Date ,/7 7 ' 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 STATZFU-WJ Policy No. G46 -734-.X4
(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 asJo-become subject to the
workers' compensation laws of California, and agree that if Itishould become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code; I shall foAwith comply with those provisions. g
,Date: ("11 7Applicant—
Warning:
pplicant 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 herebyauthorize;representatives of this City to enter upon
the above-mentioned property for.-inspecti6n; purpos S.
Signature (Owner/Agent) Date
,BUILDING PERMIT PERM&0
DAT f �� �jVALUATION LOT `�rt11 TRACT
iia 7,779 29457"
JOB SITE
qpN
ADDRESS ri�1.xpv•�
� :�> iecw.Csr+9.it l.i'i Q1Iy�L'�`�.1�1DWAK,
OWNER
CONTRACTOR / DESIGNER / EN &NEER
a'<W 1716
? P«d..',1S .t AA4CY1 :.L A (1?, ak
Lk .14TA CA 9225S
USE OF PERMIT
444 S. f R10i., I10t=4 W .t, Mi. 1s1 R S.?,- C il;,VERZO T9:+�i` 10
Z1'1S"a"0U'T'Fi' 11 C."OSf 01'
COYS:rRUC.',161•! PER 101.000.418.000 $336,54
PLAN CHErK FES, 1W-000-439-118 002;73
3 0 t-;.140--4 2 1
.10)-0Q10.4.2(> 400 it�t,6n
P M Y.Yl5IN'I'lll Yell, 01-000-41 9..000
S3'RCJ"NO MOTION ",Z - ivyM' - 100-W30-241-: 00
.till$T -at PC►B?: C PLACt.«"'.'r - c:•010 I FIF.9V '
:X133-`AYi'A1:;C'My>:�M.;",` 01,4r.PlYD P11,
31,,024y.c-'
y:�.�?,9yiY:E1p1);:tt�'�';`. ISE
(�(�
Q .iAir6 L L".i.' A ID I ES
�'SY751 ,00
1'Z, 11'.1, F.l•'. 8,JDYii ,-
JUN 2 31003 ;J ,
CITY OF UINI
FINANCE DEPT.
RECEIPT
DATE �1� �aBl
DATE FINALED
INSPECTO
INSPECTION RECORD
OPERATION
I DATE
I INSPECTOR
BUILDING
APPROVALS
Set Backs
Forms & Footings
Slab Grade
Steel
45' -/.2 •- 3
Roof Deck
.---5
O.K to Wrap
A2 —/p -
Framing
Insulation
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
I d`.f' % I C
BLOCKWALL APPROVALS
OPERATION DATE INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A. U.
Fans & Controls
Condensate Lines
Set Backs Electric Bond
Footings Main Drain
Bond Beam Approval to Cover
Equipment Location
Underground Electric
Underaround Piba. Test
Final I I Gas Piping
PLUMBING APPROVALS Gas Test
Electric Final
Waste Lines S Heater Final
Water Piping Plumbing Final
Plumbing Top Out Equipment Enclosure
Shower Pans O.K for Finish Plaster
Sewer Lateral G\ Pool Cover
Gas Test
Appliances
Final
COMMENTS:
Final I n r-.1 , ,
ELECTRICAL APPROVALS
Temp. Power Pole
Underaround Conduit
Low Voltage Wirir
Fixtures
Main Service
Sub Panels
Exterior Receptac
G.F.I.
Smoke Detectors
Final
Utility Notice (Perm)
POOLS - SPAS