0312-065 (RPL)LICENSED CONTRACTOR DECLARATION
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
C14 W Professionals Code, and my License is in full force and effect.
O 5 ch License # Lic. Class Exp. Date
O 550498 H 1.'Cz1lot
A f
�Z Date �Signature of Contra
(D O
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OWNER -BUILDER DECLARATION
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r
W w I hereby affirm under penalty of perjury..4that I am exempt from the Contractor's
~ t1 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 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).
ce) () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
O 0)
d< WORKER'S COMPENSATION DECLARATION
C) Z I hereby affirm under penalty of perjury one of the following declarations:
O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W L: compensation, as provided for by Section 3700 of the Labor Code, for the
O � Q performance of the work for which this permit is issued.
m Q U ( ) I have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
0 Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier F1='1 Policy No.
co =)
t` C)
Q (This section need not be completed if the permit valuation is for $100.00 or less).
_J (�)! 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
Code, I shall forthwith comply with those<provisions.
Date: Applicant f /�
• Warning: Failure to secure Workers' Compensation coverage Is unlawful and
shall subject an employer to'criminal penalties and Civilrtines up to $100,000, in
addition to the cost 6facompensation, damages as provided for in Section 3706
of the Labor Codeeinterest 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 inspection purposes.
Signature (Owner/Agent) jar` �" /-- Date ! /
' BUILDING PERMIT PERMIT#
DATE VALUAT'ON LOT 0312-065 TRACT
xz� �
JOB SITE APN
ADDRESS 7?-&i0!CAL1X CHIRUARU - -
OWNER CONTRACTOR/DESIGNER/EN INEER
GEORGE, ;C'UMNIK1 A. 0. ` ORRW C0145' ULTMON
77.860 CAULK 01011ARTIA 81.900 A`d:EfiltS1 52, $10
LA QVINTA CA 92253 11 10 CA 92201
(, 60)772.2848 C"Uff 1451
USE OF PERMIT
PGOL.AhD/OR SPA
IAC) USPA. ALA.L.M3/8A UUERS SHALL BE I, l PLACE AT I ": P.LASTL?R
Ik�ui�lEC`1'i+Ji4, �:QU1?�tE'iv�' E"NGi.,4;>�bi12E Nc�3' ti1�'i,CiL�t��f)
Pi k)L A.NI /OR SPA
10,000. M6 W
E4U'iW:f1' F—D COST OF rONS1111MMON
PW4 CHECK FEE 101.000.139-318 $76,05
CONSTRUCTION f?9Z 101-000-418-000 $1I'7.W
MEC"•14NNICAL ZE -- POOL 101-000-421.000 $24,00
ELYXTR1C A1, FEE — POOL, 101-000-420-000 $95.00
PITIU viMGI HE--1'CJOi, 101-000.419.000 32=7.PD
I
DEC 15 2003
CITY OF LA QUINTA
AND PI" Clf WOC
LF,S3 PRS; -PAID FERS
TOTAL .€'.F`4.�MiM S DI TR NOW
RECEIPT DATE � BY,/ � DATE FINgLED_ G/ I INSPEC
1 fl,1X,iO M01
$289.01
$0.00
r -W.05
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
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wali Insulation
Condensate Lines
Party Wali Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
f
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
r.
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX 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:
P
vaS
RojDa ZA
sj4A $ CA, �
4s
CITY OF LA QUINTA SUB -CONTRACTOR LIST
JOB ADDRESS - ��' ° PERMIT NUMBER OWNER BUILDER Aix `�yrre5
This form shall be posted on the job with the Building Inspection Card at all times in a conspicuous place. Only persons appearing on this list or their employees are authorized to work
on this job. Any changes to this list must be approved by the Building Division prior to commencement of work. Failure to comply will result in a stoppage of work and/or the voidance
of building permit. For each applicable trade, all information requested below must be completed by applicant. "On File" is not an acceptable response.
Trade / Classification
Contractor
:: State:.Contractor's License
' WoikersCom ensation Insurance:..
Cit Business License
Company Name
Classification
(e.g. A, B, C-8)
License Number
(xxxxxx)
Exp. Date
(x)t/xx/xx)
Carrier Name
(e.g. State Fund, CalComp)
Policy Number
(Format Varies)
Exp. Date
(xx/xx/xx)
License Number
Ixxxx)
Exp. Date
(xx/xx/xx)
EARTHWORK (C-12)
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1.04
DRYWALL (C-9) . . .
HVAC
ELECTRICAL (C-10) a. .
ROOFING
SHEET METAL (C43)
FLOORING (C-15)
GLAZING (C-17).
INSULATION: (C-2)
SEWAGE DISP, (0-42)
PAINTING (C=33)
CERAMIC TILE (C-54)
CABINETS (C-6)
FENCING (C-13)
LANDSCAPING (C-27)
n
POOL (C-53)
/