0301-324 (BLDG)LIGtN5tU GUN I HAG I UH UEGLARATION
I hel--liffirm under penalty of perjury that I am licensed under provisions of
H Chas! (commencing with Section 7000) of Division 3 of the Business and
w;� W Professionals Code, and'my License is in full force and effect.
t O M License # Lic. Class Exp. Date
Cy In
LUX
~o Z ir� Date Signature of Contractor
CO0�^
co OWNER -BUILDER DECLARATION
UJd r- I hereby affirm under penalty of perjury that I am exempt from the Contractor's
In 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
o6btractors to construct the project (Sec. 7044, • Business & Professionals
'Code). 11
C0 () I am exempt under Section B&P.E f �dhis reason
N Date Signature of OwnerL r J
O rn -
Z WORKER'S COMPENSATION DECLARATION
C) Z I hereby affirm under penalty of perjury one of the following declarations:
U-) � O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W Y= compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
In Q C) (yy) I have and will maintain workers' compensation insurance, as required by
O U Q Sebtion 3700 of the Labor Code, for the performance of the work for which this
dF- permit is issued. My workers' compensation insurance carrier & policy no. are:
v Z Carrier STATE IRJ11L? Policy No. 04601UNITOD"413
rb 5
r` C)
g (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 IT ns of Section 3700 of the Labor
Code, I shall forthwith comply with th�os� rpw}sions.
Date: -9`T` 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
ICU & 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.
1 -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 inspection purposes.
Signature (Owner/Agent) �` ""->`' Date
BUILDING PERMIT PERMITCMI 324
DATE t VALUATION LOT TRACT`
JOB SITE
ADDRESS D1X0. 27 (-,HAW1O2gS -Ri q=A
APN
OWNER
CONTRACTOR/DESIGNER/EN INEER
YAGA WOT k1+:8M1Wi'I1&.. .,1RJC
1 1`1..1AA PACIF(C GRNLc cAl, cojq r.Ct,x'ti&)
P,O. JBQX 1060
25*33 VOUM COAST HIGHWAY Z732, 250
[.•A. Q 111 rA C.A. 912S3
C=fiJZT11TV BY '17i•iT3 3FA CA 920W
t7ic(J)�B§-IU1t7 'CPI) 5823
USE OF PERMIT
GENERAL fat WNG
RLDID. 27: 53.260,1.25 .55.24k 'VOLUNTARY STRUCTURAL
M0 1IrlCA 711O)l9
VA.LUATIOA1 If1,S0i►:UD w
:1;,`STIMATKU C06t OF C.0115r.01iTC'.CiON
I.iIGSt?f3.4
PX'Ph%4:1':If n 9MKARY
100NOTRUC° IO.' 1 11,1E .03.-00(1�418-000 WIX0
STMONn M(71 0N' FVF,-- REST l 101-000-241-000 81.05
9�J
FEB 0 3 1003
CITY OF LA QUINTA
FINANCE
DEPT.
:JIB-!iXJTAL .00A S''TRY `rf09 AND PLAY CW—M'
�1 X7.05
LUSS fIRR-PAfI71i'.E S
S0.00
J
RECEIPT
DATE ,e r�
J
BY ;` .: -
DA FIN ED
(NSP OR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE -7
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
al I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
_
i
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
_ _
_
'!.K. for Finish Piaster
Sewer Lateral
Pool Cover
_
Sewer Connection
_
Encapsulation
Gas Piping
Gas Test
Appliances
_
Final
—
_-
Final
Utility Notice (Gas)
.ELECTRICAL APPROVALS
Temp. Power Pole _
Underground Conduit
Rough Wiring
Lova Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
ke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
--
COMMENT
.
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