0301-120 (SATT)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
F-. Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
04 w Professionals Code, and my License is in full force and effect.
O =) M License # Lic. Class Exp. Date
W 58406 B 01131/71.:
cZ r-- Date Signature of Contractor
coo, -OWNER -BUILDER DECLARATION
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I hereby affirm under penalty of perjury that I am exempt from the Contractor's
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License Law for the following reason:
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( ) I, as owner of the property, or my employees with wages as their sole
OWNER
compensation, will do the work, and the structure is not intended or offered for
CA -WAS LAB ROSAS MC
sale (Sec. 7044, Business & Professionals Code).
P10. BOX 1503
( ) I, as owner of the property, am exclusively contracting with licensed
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contractors to construct the project (Sec. 7044, Business & Professionals
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Code).
USE OF PERMIT
( ) I am exempt under Section , B&P.C. for this reason
N , • _
Date Signature of Owner
INCLUDE BLOCK WALIA OR P001,4. 75% REDUCED PLA'.d CfiFXX FEE FOR
MULTIPLE PLAN CHECK: OF 31JALF TI RS
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WORKER'S COMPENSATION DECLARATION
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I hereby affirm under penalty of perjury one of the following declarations:
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(.) 1 have and will maintain a certificate of consent to self -insure for workers'
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Compensation, as provided for by Section 3700 of the Labor Code, for the
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performance of the work for which this permit is issued.
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( ) I have and will maintain workers' compensation insurance, as required by
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Section 3700 of the Labor Code, for the performance of the work for which this
insurance &
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permit is issued. My workers' compensation carrier policy no. are:
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Carrier COMM''. V,;I&W dDIjB- Policy No. WC9026*73
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(This section need not be completed if the permit valuation is for $100.00 or less).
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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 (Own erIA • ent </',j'!! •� !' ?� Date -�`
( ) I certify that In the performance of the work or wcts permit Is ssue,
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
Code, I shall forthwith como.y with thoseprovisions.
Date Applicant
Warrfing/Failure to secure Workers Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application Is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application Is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit Issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Ouinta, its officers, agents and employees.
2. Any permit Issued as a result of this application becomes null and void If
work is not commenced within 180 days from date of Issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
BUILDING PERMIT PERMIT#
: TRACT
DATE VALUATION LOTJOB
SITE
ADDRESS Sf)� MN A IZOSA IMAZA
APN 7iSi' �ili}.t
OWNER
CONTRACTOR / DESIGNER / EN INFER
CA -WAS LAB ROSAS MC
:i rFFREY C, ST\3M :1]BA SWWf BUJIMER!,
P10. BOX 1503
4'.100 VQ14XAW' AVL;'. 0100
LA Q#UWA CA 92253
IbWWPORT BEACH CA £2660
(945)450-9911 COLA
USE OF PERMIT
VINGLE FA1vi[i Y A'IT?°A<.,.
BUIL011dt3 614 TYPE Vit, 54.72 S.1F'. 8 -UNITS. PX'Zltff1T 00E -N NOT
INCLUDE BLOCK WALIA OR P001,4. 75% REDUCED PLA'.d CfiFXX FEE FOR
MULTIPLE PLAN CHECK: OF 31JALF TI RS
FbRCHIPr TIO _ 240." 3F
CONTRACT AMOUNT 2L?2,.355.30 L5
1$MINM.ED COST OF'CONSMUC TION
M „N2;1.20 ..
Pr..Rm f'[' N'F yiY
CON1i'1`F?GFC` ON FER 101-,OM41"00 U113181SIQ
PLAN CHECK FEE 101.000-4.33-318 $321.13
IMECRANIC.AL YZE 101.000-421.000 $261.00
EL,IECTRICAL. FED. 101 -000 -420 -OW $ 47'3.02
PLUMBING FUITE 101-400.419.400 $389.00
WMONO M01'€0W FRY, R23117 101.000••241-000 $29.33
DEV, F.WPZR IMPAC I. ZEE $ION0.00
AJVr IN PUB -t IC PLACES - R.MIL 27"00.445-000 $233.82
SM -TOTAL C'OMMUC'Y'1(3k3` ANI) PL AH M.-=,
LESS PRB-PA1T :F -=r3
G=.1
DIIII,
1` ERTMEi' $flus .95FUx NO
AUG 1 1 2UO3
CITY OF Lt. QUINTA
`FINANCE DEPT.
RECEIPT
DATEBY
DAT NA -�
INSPECTOR
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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
/ • ap • O S S.T
Exhaust Fans
O.K. to Wrap
( . . 0 3 ST
F.A.U.
Framing
p 'y
Compressor
Insulation
_ O 97
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
=AytlASE F?
c • • O �T
F v.� its
.w •3 • o S
Final
Final
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POOLS - SPAS
BLOCKWALL
APPROVALS
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
8- • 03 S.7
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
.Shower Pans
O.K. for Finish Plaster
Sexer Lateral
Pool Cover
-Sewer Connection
&A-1. - 3 sz
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
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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)
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