9906-203 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter..01- (commencing with Section 7000) of Div'isi6n 3 of the Businesi and
Professionals Code, and my License is in full forc(�and effect.
04 LU
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(S =) M License.# Lic. Class Exp. Date
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LLI 656128 C 53 norm/20t
6 Z I-- p0 4t e I Signature of Contractor
(D 0-
r- �_ C) OWNER -BUILDER DECLARATION
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LU W rl- I hereby affirm under penalty of perjury that I am exempt from the Contractor's
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co 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).
( ) 1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
CY) I am exempt under Section B&P.C. for this reason
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C\I Date Signature of Owner
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< WORKER'S COMPENSATION DECLARATION
Z
0 Cc I hereby affirm under penalty of perjury one of the following declarations:
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, FZ 0 1 have and will maintain a certificate of consent to self -insure for work ' e rs,
X W �: compensation, as provided for by Section 3700 of the Labor Code, for the
0 _J _J 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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ection 3700 of the Labor Code, for the performance of the work for which this
LID permit is issued. My workers' compensation insurance car . rier & policy no. are:
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,It Z Cartier Policy No.
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< (This section need not be completed if the permit valuation is for $100.60 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_,l,;;seb�1d become
subject to the workers' compensation provisions of Sectidfw�'5MO of the Labor
Code, I shall forthwith comply with those provisions',
VDate: Applicant—
Wa rining: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an ernployer 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.
q 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 *i6 the building
const.ruction, and hereby authorize repreientatives ofthi-s`6ity to enter upon
I
the above-mentioned property for inspectiorrpurpose"s�.
Date
,,Signature (Owner/Agent)' eel i /11./
PERMIT#
BUILDING PERMIT
"04-203
DATE VALUATION -01,6,9(10.00 LOT TRACT
JOB SITE,
"-673 CWRA
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER ENGIN EER
CAIM'LLUS RES DIENIIAL GROUP
CA1,1FORNIA.PWLS &Z S.PM
5 PAIM PLA7A SM 400
774-725 JONI DKIVE, HA
IRVINE CA 92614
PALM EV-SERT CIA, 912260
(760po-9000 CUO 355
USE OF PERMIT
fWL AND SM ONLY - AL AMS I 8AftRIERS SUM.L R8 TN PLACC XY
INS-PEC'110'N
-00L AND'011,SPA 16.900.00 LS
ESTINIATEDCOST OF COINS'MIZIUJ�FILOTN
16,m.Do
PC4 JIMFT "Pj,�E 4�jJMN'
VLAN 1.341RCK FEE 101-000-439-318
COMTRUCTION M. 1014MI-41.940 WOO)
I N11W' - NICA1, FE134 ... POOL 10.1-000421-000
ORA $14,11.00
ffiLZ-C'I?JCA1. FEE -- POOL. 101�0004ZOOW S45.0
ftL%M[NQ.FE'F, —POOL 101-000-4.19-OOG
SUR-T(AAL CON,;�MIC,170N AND ),"LANCHECK
LESS PRE. -PAID FEE'S'
$0.00
TOTAL PJERMIT FEES DIJUNOW
$34 )J.010
rECEIPT
DATE
BY'
DATE FINALED
INSPECTOR
I 1-k
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
et.Backs;
Underground Ducts
Forms & Footings�
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
OX to Wrap'
F.A.U.
Framing --
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplade T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall FireWall
Ekterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS -SPAS
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
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
ShowerPans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
-Gas Piping
Gat, Test
Appliances
Final
Final - - - -------
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp' Power Pole
Underground Conduit
Rough Wiring :
Low Voltage Wiring
Fixtures -4
MaKService .
,.Sub'Panels',-','
Exterior. Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final -
Utility Notice Perm) A
COMMENTS:
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