0301-269 (BLCK)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 Exp. Date
/`Date Signature of Contractor
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 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:
O 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, , 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 workers' compensation provisions,of"Sectio 370.0 of the Labor
Code, I shall forthwith comply with those provisio�s.!� t�
r D to e: .� Applicant
. - %(�!.... P
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. K,^C
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.
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,-Signature (Owner/Agent.).— % ~ Date j 7 v
BUILDING PERMIT
PERMIT#
DATE VALUATION ,!'3 q00LOT
TRACT
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JOB SITE
ADDRESS
APN
OWNER
CONTRACTOR/DESIGNER/EN (NEER
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USE OF PERMIT
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6 FT. WALL,
1124,00 LIF
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JAN 22 2003
{, CITY OF LA QUINTA
a FINANCE DEPT. ,
RECEIPT ;
DATE
3
BY
'iih!
DATyEFIFINALED
r
INSPECTOR
J
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
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs Electric Bond
_
Footings—_��
Main Drain
Bond Beam .� v
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final -
W ",r Piping
Plumbing Final
Plu, ng Top Out
Equipment Enclosure
ShoA ar 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)
COMMENTS:
a
Bin #
cit`f La uinta {
- Y Q - . .
Buildlsig & SafetyDivision
P.O. B,ox 1 X04, 78-495 Calle Tampico
1, La Quinta, CA 92253 -'(760) 777-7012
Building Permit Application and Tracking Sheet
Permit .# ' 103
D� 4t
Project Address:.
Ciwner's,Name:
A. P. Number: ,. D QO F
f
Address: p2
Legal Description:
Contractor:
t
Ci ST Zi
h , , P: .'
Telephone: C�
r
Address:
Project Description:
City, ST, Zip:
i
Telephone:
City Lic. #:
r' r
State Lic. # :
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e q
Arch., Engr., Designer:
r '
Address: 9 • _
City, ST, Zip: ZO !
Q%,G l 'GC%Q.2�'` r
Telephone:
State Lic. #:
Name of Contact Person: [21Sq:
C yPonstnictton T e -
• ? • Occupancy:
Prolect.4type (circle one): New Add'n Alter Repair Demo
Ft. ' ' # Stories: # Units:
Telephone # of Contact Person: - (P
Estimated Value of Project: del
APPLICANT: DO NOT WRITE BELOW THIS LINE
#
Submittal
Req'd
Recd
TRACKING r
PERMIT FEES
Plan Sets
3
Plan Check submitted
/ 7[
Item'
Amount
Structural Calcs.
Reviewed, ready for corrections
Plan Check Deposit,, ..
\
Truss Calcs.
Called Contact Person
Plan' Check Balance
Energy.Calcs.
Plans picked up
Construction '
Flood plain plan
Plans resubmitted
Mechanical (�
^
Grading, plan
2"" Review, ready for correc
G
Electrical !
Subcontactor List
Called Contact Person
2a
Plumbing
Grant Deed
Plans picked up
S.M.I.
H.O.A. Approval
Plans resubmitted
-Grading
IN HOUSE:-)
a,d Review, ready for corrections/issue
Developer Impact Fee
Planning Approval.
Called Contact Person
A.I.P.P. ,
Pub. Wks. Appr
Date of permit issue s
School Fees
' ' t
Total Permit Fees
�i 108 \?(A UL
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