0303-085 (RPL)LICENSED CONTRACTOR DECLARATION
U) I hereby affirm under penalty of perjury that I am licensed under provisions of
H 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.
�.:3 ch License# Lic. Class , Exp. Date
LU 6920519 C-53 I /Qt
cZ r-_ !Date s, ' �f ��rSignature of Contractor 'H
�O�f
V coo OWNER -BUILDER' DECLARATION.
LU LU a I hereby affirm under penalty of perjury that Lam exempt from the Contractor's
W License Law for the following reason:
Z ( ) I, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure is notintended or offered for
sale (Sec. 7044; BusinessA. Professionals Code). ,
( ) -1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business. & Professionals
Coale).
u�Lc") qO lam:exempt under Section B&P.C. for this reason.
N
Date Signature of Owner
O Q,
d Q WORKER'S COMPENSATION DECLARATION
C:) X I hereby affirm under penalty of perjury one of the following declarations:
Lo H O (.) 1 have and will maintain a certificate of consent to self -insure for workers'
X W compensation;, as provided for by Section 3700 of the Labor Code, for the
m J .Q pPrmance,of"the work for which this permit is issued.
Q (� i; ) .I. have and will maintain workers' compensation insurance, ast required by
OU Q Section 3700 of the Labor Code, for the. performance of the work for which this
ll. �l- permit is issued. My workers' compensation insurance carrier & policy, no. are:
I ,Z Carrier STA.'1'!1; F014 :a Policy'No.
r- Q -
J(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 Section 3700 of the Labor
C�dsrlihfort with complywith those previsions.
-Date: 4" Aoplicant _ - -- — .. : - -:
..r i !_-�1 -� -
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided,for in Section 3706
of the: Labor.Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon ,whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this•applicaton agrees to, & shall, indemnity
& hold harmless the City of La. Quinta, its. officers, agents. and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not .commenced within 180 days from date of issuance 'of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
• correct. I ,agree to comply with all City;t,and State ,laws relating to the building
construction, and hereby authorizerepresentatives of this City .to enter upon
the above-mentioned property forin pection purposes. . i}
__, -(Signature (Owner/Agent) +' "' D&te
PERMIT #
BUILDING PERMIT
0303 0115
DATE �,, VALUATION LOT TRACT
SIOM 71
JOB SITE
ADDRESS :�lG•�i�r C�ii�{'w� I)i�`FF!: _
APN _
OWNER
CONTRACTOR / DESIGNER / EN 1NEER
TSR. ANDlQR MRS. C3,E11:t1`73:;R
CAHU f_I.�A:l: 0,'_1L Gf�1!3�I:i?UCi'1:CLt i; i2di.;.
5 2 -660,00 , GKr(> UJUNFE
78-710 LA_E'.117MA DR., ,LA QUDU
I,p+.quirTl.'r1 CA 142253
PALM DE"T CA 92261
'?60.6602 Z44
MAY L
USE OF PERMIT
:[''001:,AIM/0R IM.A.
[kCYOLAWA, IWAY FOUNTAIN. ALARMS/BAFtRIR-RS SHALL, BE IN PLAC'L
AT PRE PUASUP, rNSPrr-TrO1$, NOT 11d(":[.Ilar"D
POOL ASID/O[t. VA, IADPP.00 US
'Et F133MMI) F..10sr ' 0111 L.ONFIRMC13.014
PT4_'PM€'r. ME IW iRY . .
PLAN CHE('1"' PET 101-000439-316 $163:x(4
C;1i�!STR.[IC [ CfiN .EZ 101-000.4.18-000 $752.00
MECHA-141CA:1: ' t,�� _ • Y001, 1014.00-4121-000.9.1 , ° UAW
JK%FC`I R1C;AL,Y+' UK °- POCIL: 101-000-420-000 $ai .f90
PLUM: THO ME - P001, 101 �0j00-41'9-0,00 SMl,4%
11
ql
MAR 14 2003'
CITY 0i• i,r" rjtil�S'� j
>'. B-'1 CYrAL CONr'glRC1C.'3-TON ANT) P A1N' C:HROK
$511.80
'XD F'i S
;Ci. Gt►
110T&L 1i'. RIA1:?' :sPT.9S DUE now
9511 z0
RECEIPT
DATE ` J
BY .
DAT F A D
INSPE R
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Fomes & 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 e75
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Electric Final
Wastrta'nes
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
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: l
`