0302-084 (BLCK)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Fes- Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
N W Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
dr
W 463407 C29 B 0191.130 i C
Z ti Date!'%=' '= Signature of'Contractor
O �- --
r` F- CIDOWNER-BUILDER DECLARATION
Ha I hereby affirm under penalty of perjury that I am exempt'from the Contractor's
U) License Law for the. following reason:
Z ( ) 1, 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).
ch O I am exempt.under'Section , B&P.C. for this reason
LO
N Date Signature of Owner
O C4
CD
d Q WORKER'Sr COMPENSATION DECLARATION
'� pZ 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'
X. a 1' u- compensation, as provided for by Section 3700 of the Labor Code, for the
0 J performance rformance of the work for which this permit is issued.
1:0Q U ) I have and will maintain workers' compensation insurances as required by
d Q Section 3700 of'the Labor Code, for the performance of the work for which this
d H permit is issued. My workers' compensation insurance carrier & policy no. are:
Z CameyaCiUUR`'icuq�'IVi EtiF t Policy No. }
Co
�a
g (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,
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 comply with thosel provisions.
.Date ., : %� - Applicant
Warning: Failure to secure Workers' Compensatipn 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
fora 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. l 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 forr,,inSpection purposes.
-Signature (Owner/Agent)Date,,,:-'
BUILDING PERMIT PERMIT#
t�3�'3r;L-t)4L•�i
DATE. VALUATION LOT TRACT
t r:�l.0 x l.�flf, 5�1,�'�GIDC1
JOB SITE -
APN
ADDRESS 5.1_4,10
OWNER
CONTRACTOR / DESIGNER / EN (NEER
t9.t�1 f)Y iMa`Y)ER
PDRUR'r C0x .r4R lJ T..I.0
52 -440 DR, G,p,I-0 ,7 RIV L
7 3kKIP MMISt N "Y'r
1A QU1I T1A CA 92253
PALM DR111MT CA 92215,0
(-160)�I46- 1227 ('I3'Uf 04554
USE OF PERMIT
1810 LF, 4' OAR, al 'W.A.IJ, 120 L.F. 780 PLANT= 8` t -d lw BOTH
ORC0 0Y13TE,M
G FT. WALL 19E1 LIG i.>r
F`s. MOZATFI) COSI' OF (110K i'%R`C7t~:°;i7iON
4,5M.00
I:'Ti ici►✓li;il' FFF 911MII/ltS.RY
CCxiJS')'ItifC �iO�f t%1!3� 1 t)]-QtI>t�al �-th�p 3"!1,(1!)
D Q
FEB 1 1 2003
CITY CW �A QUIIVTA
FINANCE D
r
SUB -If GTAL r. ON91MUC`Izf,W AND PLt'iU CF)FM
tr/2.00
RECEIPT
DATE
BY /
DATE FINALED
INSPECTOR
INSPECTION RECON®
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
POOLS _ SPAS
BLOC KWALL
APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
, 03
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
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
Appliances
A
Final
COMMENTS:
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)