0301-331 (BLDG)LICENSED CONTRACTOR DECLARATION
I her ffirm under penalty of perjury that I am licensed under provisions of
k- Chak_ , (commencing with Section 7000) of Division 3 of the Business and
04
W Professionals Code, and my License is in full force and effect.
p :D M License # Lic. Class Exp. Date
0 731152 B mc 1103
LU
6 Z I-- Date Signature of Contractor
co 0 Ir
F" 0 OWNER -BUILDER DECLARATION
aW I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) 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 & Profe sionals
Code). ;
C'`) () I am exempt under Section ,.B&P.C. or this re'aU1
s,�d
O N Date �s,� %: Signature of Owner
a Z WORKER'S COMPENSATION 6EC ARATION '
o1 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 LIL compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the'work for which this permit is issued.
m I have and will maintain workers' compensation insurance, as required by
O U < Section 3700 of the Labor Code, for the performance of the work for which this
d rn f— permit is issued. My workers' compensation insurance carrier & policy no. are:
Nt Z Carrier NATE 1TLYND Policy No. tMdv➢CiI+11YdH3t1�4:9
cb5
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(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 hould become
subject to the workers' compensatio provisions of actio 37 0 of the Labor
Code, I shall forthwith comply, with those pr ision .'/
Date: r� Applicaht' '
® Warning: Failure to secure Workers' CApensation coverage is unlaw, P nd
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 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 representativep, of this City to enter upon
the above-mentioned property for insp ption brrpp • ses. .
Signature (Owner/Agentj` Y Jy" Date i
PERMIT #
/BUILDING PERMIT X301 141
DATE•'� _Z, VALUATION S7^*.00 LOT TRACT'
JOB ADDRESS .91,1)473. 3-4 t'��1At4'II� ONS-,Ri�l.9
-1 - 4�0
APN e y
OWNER
CONTRACTOR / DESIGNER / EN (NEER
PGA WEST Itt•..f M, C1AT, ASSOC:., INC
i)EL MAR PACIFIC (.IENIF.�F.. COA7TRt� i °i� JI
I,,(), BOX 1060
253 201M1 C10AKr FltGHWA'Y STR. 2..50
1A Q010TA C.A. 92253
C.fi3?D]:1 K13YIkf1kC SHA CA 920VI
•
r�'/riAtf�3S>i�iZd; C'I?.:3.A� �13:7;t
USE OF PERMIT
O:I:F-WI R i.:AL Itii.7'AU?i O
Ii1.,13t7. i.. ,&M-932. Cif.1Lt1NPCtteRYTrIZUi.TUR.Al,
MOT)1f71Y; A'iWHO '
VALLI.A'f ION 7100 1010 i..3
96794ATED COST OF COWN7RUVrION
i'XIM9' II'.�'It' SUMMARY
(XINS`ITRUG110H M, l
3 d'a8ONO hdOT1011 PLEA: - RESID 101460-2,41 -000
FEB 03 2UU3 •I�
CITY OF LA QUINia
FINANCE DEPT.
SCIZ3-'1�'{ABY, CM, M" 'ldA ITOYd•Awl) PLAN CIM•9Cr,
4
$90.70
:P1R3'r>,PAW : RES
*(M)o
TUFAL.1'KRZ%4T'F1,5s'b DATE NOW
RECEIPT
DATE,/
BYt`�
DA FIN ED
INSPE
I
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE -7
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
BLOCKWALL APPROVALS
-- POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground. Electric
_
Underground Plbg, Test
al
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 A
Pool Co4er j
Sewer Connection
Encapsulation
_
Gas Piping
Gas Test
_
Appliances
Final
—
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Undergrodnd Conduit
o
L Volta
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
F.I.
oke Detectors
emp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
3
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