0301-122 (SATT)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Q�K.l.Pter 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
584656 -B 011311«t
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 Sicnature 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.
x( A 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 COA9MXIrtCE&jrIDU3, Policy No. WC9992M.
(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/c, 3700 of the Labor
Code, I shall forthwith comply with.those proyisyons. /
Datei'i'� Ap • (icantf' �- f •/ �
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 inspection1purposes. r
Signature (Owner/Agent);'%`` / [ 1 soh Dated l
BUILDING= PERMIT . PERMIT J1 r " ' •
EB: 1-122
'
DATE VALUATION $29315217120 LOT B�16 TRACT 29909JOB
SITE
ADDRESS 610 S .A ROS. P1'v.o
APN
OWNER
CONTRACTOR / DESIGNER / EN &NEER
CAMTAS LAS ROSAS 1.:LC
3F.7nYY C, STONE DDA STJWNi1T Bli,CT.17:ER1
P101 BOX 1503
4700 V'01iI4..AIi W N AW.41100
1,A qUTNTA CA 92253
1`1AVPQXr PEACH H CA 92660
(949)450-90,911 e%:
r
USE OF PERMIT
Bt1ti.D NO #16 TYPE A, 1473 S.F. 9 -UNITS. PERMIT DOLS NOT 1
INCLUUF, DbOCK 113ALU Oft POOLS. 931`o 1 KOUCB17 PLAN CF11310 C WE Fk",)R
MU131PLE PLA14 CRE:CK OF S,AId4Z TYPE
PORCH/PATIO `.i9G.QA NF
CONTRACT AMOU04T 242,:355.Zd L'g
WYMAM C09r OF C0KFfRUC1_101Y
79 ,527.20
PEW -Mr b t3M AR.'3t
,
CON9TRUCTION FEE 101-000-4113-000
lirAX CHECK FLE 1011-0O"39-316 021.17
MECIIAN1CAL,FEE 101.000-421.-000 $263.00
F.L=TRfCAL PEP, 101-00". 20 -OW !r:z.02
PLL1MBINO FEF 101.000-41 9-000 $: 9100
STRONG MOTi0Af FEE - RE3113 101-000-241-000 $30.39
DEVE PRP IMPACT FEF $14008.00
.PtwRT 1N !'FJRMC PI ACES - RZSIL 210-000-445--000 $23:3.07
h
r.
w' IB-Tt%I'F L CF.WSTRUCT1.G)NANLk PJ..Ayi��1
�18,935,86 • , '�
LESS .7"n,lw'aJ,6'•,.CD �'A✓.IIS
FIRE -PAID FEES
9;0.00 ry
ile
PrRyffr MIS E11% NOW
W,
AUG 1 1 2003
ITy OF LA QUIPI7A
RE EIPT FINA
BY
DA FINAL D /
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Slab Grade
J3
Ducts
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
• ZZ. 3 T
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
7- C.4S6
�[ • O
•, • o
Final
Final
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
� 0 � S,
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Z . 1,p3 .57
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:.
G N4 -r Z-- 3, Id- a.3• d --%j
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