0301-325 (BLDG)LICENSED CONTRACTOR DECLARATION'
I he , affirm under penalty of perjury that I am licensed under provisions of
.F_ Cha, . (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 =) ch License # Lic. Class Exp. Date
LU :'3315 w E•t 111C" 3131 /03
oZ r-- Date Signature of Contractor
0 C
I.— OWNER -BUILDER OWNER -BUILDER DECLARATION
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~
0 -
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).
(k) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
M () I am exempt under Section B&P.C.•fo his reason
N
ON Date Signature of Owner
0)'
a Q WORKER'S COMPENSATION DECLARATION
p M I hereby affirm under penalty of perjury one of the following declarations:
U-) Fd— O () 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
J Q performance of the work for which this permit is issued.
Q U (t) I have and will maintain workers' compensation insurance, as required by
O Q Section 3700 of the Labor Code, for the performance of the work for which this
0)H permit is issued. My workers' compensation insurance carrier & policy no. are:
v Z -Carrier OTA..TE NU14D Policy No. 046011.JAilTUGMIS
ob :5r` 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
3 subject to the workers' compensation rovi`slons of Section 3700 of the Labor
rJ .n.
Code, I shall forthwith comply with thos r,Qv�• Ions.
r bate:r;' / •; -a: Applicant Ii ,\.i _
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
�M^Vip & 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, /4nd-State laws relating to the building
construction, and hereby authorize re resentatives of this City to enter upon
the above-mentioned property for insp6ction purposes.
/f Signature (Owner/Agent)gl Date
PERMIT #
r.BUILDING PERMIT 0;101..,
DATE ° VALUATION T14AA LOT TRACT TO
JOB SITEY �.
ADDRESS MJ)d. 28IMMWIORS --WM..RA 455 •� I �
APN � Y
OWNER
CONTRACTOR/DESIGNER/EN (NEER
PGA 'dVjlzlTR SWEI31dALASSl`7C,U4C;
1' 9EY_,.NiARk'XVSC"Ci>",N ft.ALCONIV,.!ACfU
12,QFAUX ION
,,533 SOUMC;OA,5TMGM WAY STf 250
LAQAJINTA CA 92233
I:.'.K1KDfFF D Y TRk 3EA CA 9200`1
(760)635.1010 Cali# 5f$23
USE OF PERMIT
4: 5.9.220, S,,,,11,21' 35-XW, 35.196. YC3LLI1 T.ARY
IS'P'><•iLrCTUi AI, MODI'MCATIONS
1�F��,UA.iaC+?d i4,ouif,ni1I's
Klaz"C:iftttATRDCOW OF t`ONST'RdyM;0111
1.4,0(K).OID
!'Y:'b7Mrr VkT. OUi V
("ON, TRUC:TION PRE 101 -000-418-000-
S9'RONCI MOTION PRE - RESID 101-000-241-000
1' �f
FEB 0 3 7003 a1
v
CITY OF LA QUINTA
FINANCE DEPT.
&MA-10EAL CO IO b'%4U1..1.1O JAIM PLAN Cf -.T rr)
TC>'I'AL PEi'Xi11 ff IrKE'S DVE NOW
$154A l
i
RECEIPT
DATE
BY ^^
DA
IN ED
INSP,§VR
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
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
alI
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping ,
Plumbing Final
Plumbing Top Out
_
Equipment Enclosure
Shower Pans
Se-xer Lateral
O.K. for Finish Plaster i
Pool Cover
_
Sewer Connection _ �-
Encapsulation
Gas Piping
Gas Test
Appliances
Final
_ —
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Pqwer Pole
'Undergrdund Conduit
Rough Wiring
Low Vottage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
-" F.I.
ITDetectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS -
(� i
M