0301-326 (BLDG)LlL;hNbtU UUN 1 HAL; I UH Uht;LAMAI IUN
I her affirm under penalty of perjury that I am licensed under provisions of
Chak,i (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
733152 3/31 M
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).
I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
() I am exempt under Section B f his reason
Date 3/.. '31 • 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
$ ction 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 ST .46TF') -NE) Policy No. 04601UNTT009415
(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' compen ation provisions of Section 3700 of the Labor
.Code, I shall forthwith comply wit ,tfae s qFI visions.
Date: Applicant V
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on .his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorizeepresentatives of this City to enter upon
the above-mentioned property for i spEktion purposes.
,r
Signature (Owner/Agent) :_�.' Date
BUILDING PERMIT PERMIT#
t7�! ii ••��fD
DATE % VALUATIONi�i,z. , LOT TRAC
J00 011 ADDRESS MAX;. 29 CU. =`1 OM -.1r XVM!r�EPN
-
OWNER
CONTRACTOR / DESIGNER / EN (NEER
PGA W ff }2.�'�IY))±,iaTIAI .A380C., INC.
IST, kAp"R 1✓.t`r.1'NNIC !"�X'N3.:ktA:t: CXYNTPkc.',t,C>i
P,0. BOX 1060
X.533 ,4nrTt7.3 (Y( VIXT171:GRIWAY M. 250
LA QtliiAl'TA CA 92253
C!' RD .E.Y' I -fl$ SEA CA 920TI '
USE OF PERMIT
CJYNI?RAI_ BURD1 0
13 1_1X1 39: 55, 120, &111D, 53-M. VOLUNTARY STRUCTUR.A.L,
M()01FICA 'PIONS
VALUATION 1tes4G.Ufl 1
EW.tii1IA`MID C09f OF C0.11Y.17RIX:'1:10itiT.
Pk3affF ME SUMMARY
COMM) 101-000-41f3a(1iO 5116.(10
STRONt,3 MOTION FE.E'. - RESID . i U1 -M-241-000 04
a o
D
I1
FEB 0 3 2003 '
�v
CITY OF
LA QUINTA
FINANCE DEPT.
aM.- OT.AT. CC+1�:Yf72.P..I TION AMNO fly- +i CY-MM
1"F M.f2."�'�'iLt .I10i
-
RECEIPT
DATE '
! .
BY �•
_.._..
D FIN
JINSPEIL
INSPECTION RECORD
OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR
BUILDING APPROVALS MECHANICAL APPROVALS
Set Backs Underground Ducts
Forms 8 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 8 Controls _
Party Wall Insulation Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final POOLS - SPAS
BLOCKWALL APPROVALS 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 Neater Final
Water Piping Plumbing Final
Plumbing Top Out Equipment Enclosure
Shmver Pans O K. for Finish Plaster
Sewer Lateral Pooi Cover _
Sower Connec"on Encapsulation _
Gas Piping
Gas Test ----
Appliances
^ i Final
COMMENTS:
Final
Ut;ity Notice -(Gas)
-711
``IP
ELECTRICAL APPROVALS
Temp. Power'Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring j
Fixtures
Main Service
Sub Panels
Exterior Receptacles
F.i.
Yoke Detectors
Temp. Use of Pourer
Final
Utility Notice (Perm)