0301-328 (BLDG)LICENSED CUNTRACTUR UECLAKAI IUN
I her ,,ffirm under penalty of perjury that I am licensed under provisions of
Cha(commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
7;3152 YA 111C, ' 3/311/03
Date Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 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).
retractors
as owner of the property, am exclusively contracting with licensed
re)tractors to construct the project (Sec. 7044, Business & Professionals
Code).
( ) I am exempt under Section B P.C. r, is reason
Date % Y ( ;;a Signature of Owner) '
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
( ) I have and will maintain a certificate of consent to self -insure for workers'
compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
I have and will maintain workers' compensation insurance, as required by
Sdction 3700 of the Labor Code, for the performance of the work for which this
permit is issued. My workers'. compensation insurance carrier & policy no. are:
Carrier STA.TT.ti RTH.D Policy No. 04601 UNIT000194IS
(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' conipensatio'rrovisions of Section 3700 of the Labor
Code, I shall.fArthwith comply wi tho. pr visions.
Date: IL—J
-,. 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 r presentatives of this City to enter upon
the above-mentioned property for ins tion purposes.
Signature (Owner/Agent) 7 / Date/
•I
BUILDING PERMIT PERMIT#
0301
0
DATE _VALUATION yLOT TRACT
JOB SITE
ADDRESSI3I.1r11,:.:�1. ;..H.AEIPCJIit� �I236+1iFk2A 55_ ptj
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
PGA Mgt R.l''.S]iDE1,511AL A080C. y Z%Cr
DEL M.R.j.:,1c'.f CI IC CIEW :R.f: L {.'.0NYll.1.11:!,.L'(;,J
P, ().YAOX I Of, 0
2 1 13:7 00 t:►°I l (,()for ATCY11:'t AVY 1,S)"r 159
LA QTJTMfA CA 92253
C;AtiZ+"'aF.if`+1LP -SV ITIS ��A. Cs�.9-2000
C��f
` 7(ro(,lfi5-�VJV
USE OF PERMIT
t�,ill+lJ��fSfit.::i31J3.�T.l]tiC�•
181J)L1. 3q: g545q 55-n40 VS -030. VOLUNTARY STRUCTURAL
MODIFICA VOWS
VAIXIA` ION 1COW 00 i, 5'
.O.tiS-K.dLC6dY.6KD 4 OF1 d7 (JA' (XI IJIA".UMd.O
.R .'�, a A•t�=�. .�
COMTRUC TI044 iU IGS) -m- .0 -clog #)26,09
SITH.O'PdCI NOTION WE MID:* 1.02-000-2.11-000
FEB
03 1003
v
CITY OF LA QUINIA
FINANCE DEPT.
�ttJFs-1 t.)TAL CC?),4114T'RU °l,10H ANI) PLM Cf1 .,fit
II t i.T.1g
!Y33 k'.Eti f,sl'A111 fT1?
$C).f)a)
TUML PER11t4T-C 1", 01J'O NOW
312.7.05
dof
RECEIPT
DATE
f r!
D E FI ED
I INS TOR
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 Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS •- SPAS
Steel
Set Backs
Electric Bond
I
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
al
Gas Piping
m PLUMBING APPROVAL'S
Gas Test
I Electric Final
Waste Lines.
Neater Final _
Water Piping
Plumbing Final
j
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
_
Pool Cover
_
Sewer Connection
_
Encapsulation!
Gas Piping
Gas Test
i _ --
t Appliances_
—'
Final
Final
t Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. rounPole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
jl;oke Detectors
emp. Use of Power
Final
Utility Notice (Perm)
— COMMENTS:
!
45iC42f2-
/