0301-121 (SATT)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
584656 B 01131t2c
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:
( ) 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
S ction 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 C,O ?4 ERC.R&INDUS' Policy No. wc%Awn
(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 provisionSNof_S.ectioh 3700 of the Labor
Code^I•siial orthwith comply'with those;provisions. 1
Dates ��, APPlicant� _
s -
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 propertrty.for inspectio purposes.. -�
Signature (Owner,/Agent)fAVw ILL �r�!"' Date✓ � : �
BUILDING PERMIT PERMIT#
DATE VALUATION
F�R LOT __ TRACT 29909
09$2913.527 D-15
JOB SITE
ADDRESS .50.4620 w AMA. H,09, 4,m FL�li 7A
APN 770-020-011
OWNER
CONTRACTOR/DESIGNER/EN (NEER
CASIT O LAS P,03A.19 MC
JEE"U ' C. ffrOM DBA. SgJMW.r BW,. DER,'
P101 BOX 1503
47001A0 MARMANAVE.4100
1sAQjYD3T4 CA, 92253
99"atPOIRTBE:ACH CA 92660
(949)450>9911 Zv�I.#
USE OFPERMIT
1.7 yin �, /���yy�y�
►: LF G.L.R? FA L.Y .KNACIM)
$'UIf LIMO #15 T YPE ,Ft,,. 54iA SY. &U31ITS. PERMIT DIDIM NOT
rNCLUDR BLOC1i WALLA OR POOLS. 75% RKOUCED ;['TAW CHECK FEE FOR
MULTIPLE, PLAN CHK'K OF S"Z TYPit
PORC1 IRAT1O 040.00 Sr
CONTRACT .A MOM IT 2,3 .353, 20 IS
ESM'.IA.'I'I D MUM CONS'1`I'ii9MON
mi j's27.20 -.-
PERM Y" MEs, MARY
COI+ STRUCT)O1v FEE 101-000-418-000 $1,318,50
PLApd CHICK FEE 101-000.439-318 1521.17
;11i11CtUNICAL PEE 101-000-421.000 $243.00
i1 LF,,CTRIC AL P.M. 101-000.4-20-000
PLUMBXNO FEE 1.41.000-419-000 $389,00
STROHO MOTION t?FF, • R"� ID 101-000-241-000 529.35
DEVELOPER I MPACT FILL? M1008101
ART W YUBL.1.0 PLACES d 38X3.11 2'70-000-445••000
Ad3T18U TJOK.AN D PLAX C''1�.tt.C1K
$18,939.86
D A IMS PR19-PAM SM-
$0,00
AUG 1 1 2003 OTAJ,P,KIM If".8 00E .NOW
CITY OF LA {aUWTA
FINANCE DEPT -
ty 8"151
RECEIPT
DATE'"
1
BY
DAT INA E
INSPECTOR
•
f•.. �,
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
�J
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
ifi�Cl.SiIF' 7�
O • , 0 3
s>•sbhs
o• . a 3 s
Final
Final
BLOCKWALL APPROVALS
steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
`
Final
Gas Piping
A
PLUMBING APPROVALS
Gas Test —
Electric Final
Waste Lines
8 2( 6 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
p ;3/.a3 S7
Encapsulation
Gas Piping
Gas Test
Appliances
,
Fjdal
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:
�%tao� Ovia✓!�a
!m- 3<•a •3 57