0301-325 (BLDG)LICENSED CONTRACTOR DECLARATION
I hepaffirm under penalty of perjury that I am licensed under provisions of
Fes— Cha 8 (commencing with Section 7000) of Division 3 of the Business and
t14 W Professionals Code, and my License is in full force and effect.
C =) ch License # Lic. Class Exp. Date
� w LO7a 1i� BHic 3/3A1 5
oZ r� Date Signature of Contractor
O"r
r-
F- O 0 OWNER -BUILDER DECLARATION
WLIJJ I hereby affirm under penalty of perjury that I am exempt from the Contractor's
co 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). {
O I am exempt under Section B&PP fo f ,#�iis reason
LO
N Date s, P Signature of Owner 1 i
O N_
CO
Q WORKER'S COMPENSATION DECLARATION
C) ZI 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'
X W LL compensation, as provided for by Section 3700 of the Labor Code, for the
Otn Q performance of the work for which this permit is issued.
I have and will maintain workers' compensation insurance, as required by
U Q Section 3700 of the Labor Code, for the performance of the work for which this
tl rn I— permit is issued. My workers' compensation insurance carrier & policy no. are:
It z Carrier STATE FUND Policy No. 046(1?XJTU#US41!i
O 5
�a
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' compensation foJislons of Section 3700 of the Labor
,I .r.
Code, I shall forthwith comply with thos�prqu�slons.
/bate:,f' ;1 �� 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
4 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,aaj��d-State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspQ tion purposes.
r ,r
Signature (Owner/Agent) ; `s^�'Date
PERMIT #
AA."BUILDING PERMIT W301-3-2,-gDATE{
VALUATION $14AM LOT TRACT
JOB S BLDG. 28 C.}IAI�'.>rE'I(3;^tS-�.•.><ZIl
ADDRE
APN Y M `
OWNER
CONTRACTOR/DESIGNER/EN (NEER
15(bA''JV1Tb" T PYRI JLk3'I'ie , MSOC., .INC
DEL, :&,rgAR MIMIC GENERAL i. OITIVA C KIIJ
LA Q11MA CA. 92233
C:.Kt L7fFF B Y THi 'M?A CA 9200`1
(76t3UW-1010 C."Jtil* 5823
USE OF PERMIT
BLOtf.:1&I: S3•Q2D, 5i•a3d„ �(h_53-19d. V01.UNTARY
S` RILICTURAL MOL3WICArIONS
VALUATION 1,S
i(Io :iMl I". COW OF CONSTINICTION
] 4,OiD[s.i1�f
Pkumrr ITT SUMMARY
+00149--TRUCTICiN FRE 101 -CM -41 8-000 ib33.00
STRONOMOTION FEE >RESID 101-1It71'1•-2AI-(CYO
a
o o n
I'!
FEB 0 3 2003;
CITY OF LA QUINTA
FINANCE DEPT.
&UB- rc A.L e owErmo cf nom, Ami) Pi -AN a
$114.40
1Y"iTA L pF:IwrMIS DUE Now
$154,40
RECEIPTDATE
f
By, ..r __16AJ
IN ED
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 Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
_
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings i
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground PIN. Test
at
Gas Piping
PLUMBING APPROVALS
Waste Lines
Gas Test
Electric Final
Heater Final
Water Piping
_
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
Serer Lateral
_
OX for Finish Plaster
Pool Cover
_
Sewer Connection
_
Encapsulation
Gas Piping
Gas Test
Appliances
Final
FinalAL/-
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
.. F.I.
oke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS-.