03014-329 (BLDG)LICENSED CONTRACTOR DECLARATION
N I her affirm under penalty of perjury that I am licensed under provisions of
F— Chak,_ (commencing with Section 7000) of Division 3 of the Business and
C'4 U1 Professionals Code, and my License is -in full force and effect.
C 5 ch License # Lic. Class Exp. Date
LO
w 7331.'52. B 111C' 3/31/03
r--
cZ r-- Date Signature of Contractor
to 0
_J 0o OWNER -BUILDER DECLARATION
H a co 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 & Professionals
Code). { '
co O I am exempt under Section B�P.0 ib�tt this reason
O rn l , 'Date .z :',I Signature of Owner`_—k _!
aZ WORKER'S COMPENSATION DECLARATION
o Ix I hereby affirm under penalty of perjuryone of the following declarations:
LO H Q () 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
m0Q performance of the work for which this permit is issued.
Q L) I have and will maintain workers' compensation insurance, as required by
Q U Q ection 3700 of the Labor Code, for the performance of the work for which this
a rn F— permit is issued. My workers' compensation insurance carrier & policy no. are:
v Z Carrier 2TATE. FOND Policy No. t¢!601>: NI-10bFs! 411
Cb O
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' compensqtionvisions of Section 3700 of the Labor.
Code, I shall forthwith comply with1thos visions.
'Date: ! ^l `a Applicant
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, 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 insTapon purposes.
Signature (Owner/Agent) ` -!` Date
BUILDING PERMIT PERMIT ry
(aa144 9
CT
DATE / VALUATION �ila LOT TRAJOB
SITE
ADDRESS 13100,32 t,'1atfaONn-irrcar. S5 __610
APN -
OWNER
CONTRACTOR/DESIGNER/EN INEER
PGA WM )RZ8MT-VfiAL. AHK C".., ITC
DEL 1% A R PAC71FIC GEN IUJI C�AdTY..An.1 3
TI.O. I.OX 1060
2533 SOV 111(:C',.E iFf I�i'C.HW.� Y W.F..1-50
aLAQUINT�A. CA 92253
ckR,Dir-1?B Hk'&—L,A cA 92007
(7,,0)635-1010 CBI,If .5823
USE OF PERMIT >
;SLUG. 32: 55.0201, 35.014 55-M. VOLUNTARY STRUCTURAL
SJ,tt.IX40'I YN 9000.00 4
EFIDW11W C -09F 4?F (1101`IS.J' (TC1IO11
10'sm.0o
Ph.'4n���lii'I' afi 9UMWAkY
CaN311110`PION VFX 10) _000.418_ 0(► S! X OD
STRUN>;! MOT1014 FEE . KILSO 11011-000-241-000
FEB 0 3 2003 r
CITY OF LA QUINTA
FINANCE DEPT.
WB -TOTAL C ONRMI.1' "l -I N AMID PLAN CTWX
$12.7.05
um
$0.00
TOTAL PERMIT FEEN DUUi NOW
RECEIPT
DATE
/ /;
BY%
"+....._
E F ALE
INSP R
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 Wall Insulation
Condensate Unes
Party Wall Firewall or_
Exterior Lath O
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
Neaier Final
Water Piping
Plumbing Final
Plumbing Top Oul
Equipment Enclosure
Shower Pans i,
Q.K. for Finish Plaster
Sewer Lateral
Pool Cover
_
Sewer Connection
Encapsulation
i
Gas Piping
_
Gas Test
Appliances
Final
_
Final
Utility Notice (Gas)
F" ELECTRICAL APPROVALS
Temp. Rower Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
Q.F.I.
oke Detectors
emp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
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