0305-166 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (.gommencing with Section 7000) of Division 3 of the Business and
Pro%&s;Iohalsicode, and my License is in full force and effect.
License # Lic. Class Exp. Date
69223
Date 16) _26 a 0_31ignature of Contractor~
OWNER -BUILDER DECLARATION f
I hereby affirm under penalty of perjury that I am exempt from the IContractor'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 r
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 STAT'L? JfCJWU Policy No. , 044-02-0014319
(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
,EOde, I shall forthwith comply with those provisions.
Date:;,'£•- 2,1- Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to crinlinal 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) '�2> "YC -d Date J19��3'��
BUILDING PERMIT : PERMIT#
DATEVALUATION ` LOT-`� TRACT
b:5X3FtfI2,�€l 1'3 3t1.��"S1
JOB SITE" I i
ADDRESS
APN
05 -Y19"1YI
OWNER t
r
CONTRACTOR/DESIGNER/ENGINEER
3AR :Y' 1',
965 kJ'(: R'. . &CrON:D ,AVJa=.
TA Q1.TM3.A. CA. •92233
VPX�4M CA •' 91786-,•1rZIl
(�'09i9€I•�99:f CI 3339
USE OF PERMIT
laING1A F'.AI MY DVU1:RDLT,h G
4,350 SQ.Irf1 SRC; .PQRMI`C II®PS'NOT 1WC1,TJA9 HL0C K'WAI L,% POO1, ;
OR DRIVEWAY APPROACH. 2001 C:OaDF.5
CUSTOM CONSTRUCT16H 41350..00 up
PORCHIPAT'IO . 517•;1V SP
GA1t.oh,0E/E ARDOR 6%00 S
E sxWATED COSIT O CCl ItiI:1? d Cr "TC3YV
:� �..3.C9
CONSTRUCTION IEE 3 011-00041118-000 $1,S46.09 ,
PLAN Cl• ZCK FRE 101:-000_439-318 31,adb.93
FEE DVOSIT 101-000-439-31S .$1,000,9a
ARY•: HANICAL F'E.1 101-L�Qti-�lral,�Ot�Q 41I�1,5c1
ELECTRICAL FEE . 101!000.420.000 $247,X,;
Pi•t71df&1ING PEP,. 101-000-41.9,000 �zcn.fl�
S'I'Rb2dCl MO'. 1014 Nk.RMI13 101.000-241-000 935.36 "
t1AkL')'➢w P'FE `101-000-4ZIr-600
DEWELOPER IMPACT FE E
ART IN PUBLIC PLACES • I1.1 SIE 270-000-445-000 $396.44
,
:SfJB-•TUrAL....... 0 C° qlq AITD I'LA T CE -N
x;6,3 49 1.5.0
SS FRE-PAIDTVS
41,000,00
DI Loa
OCT '2.0 2003
CITYO'F LA QUINTA ;
FINANCE DEPT. • -
r7
RECEIPT
DATE
BY' /
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
SqLBacks
_
Underground Ducts
Forms & Footings
A)
Ducts
Slab Grade
v v/
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
1A
F.A.U.
Framing
Compressor
Insulation
p
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
4 4z
Drywall - Int. Lath
Final
Final Z- 37
BLOCKWALL A PROVALS
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
v
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
Appli noes
Final
Final
Utility Notice (Gas)
ELECTRICAL AP ROVALS .
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service D
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) / `j
COMMENTS
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