0301-322 (BLDG)LICENSED CONTRACTOR DECLARATION
I her, " affirm under penalty of perjury that I am licensed under provisions of
Cha • 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
733112 1i HH, 343 1 /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).
(b.) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & P,fpfessionals
Code). j
O 1 am exempt under Section. B&RC. for this rea hn f
Date /- I ' 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
Section 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 VATE FLIM) Policy No. 1A 601UN1110041.5
(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 Californi , and agree that if, I should become
subject to the workers' compensation provisions of Sre for'i 3700 of the Labor
Code, I shall forthwith comply with thosg'provisioris.//�
l
Date: .1 - °� f .-Applicants
Warning: Failure to secure Workers' Compensation coverage is unldw,fu) and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
1 certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property fo inspect
io X, (poses.
7/ 7 .
Signature (O.wner/Agent)•-- % ��
BUILDING PERMIT PERMIT#
0.
DATE VALUATIONLOT TRACT
r• i
JOB SITE
ADDRESS 131,131G. 2.5 ('•TJAMP'IOKS-J$.8VJF.RA 33
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
1�a& wi%:.1=l 1auffl) wri#:f..1 :.C.., n4c
I11V:C.1�sF.A Z PAC°tE�A GIR& �J�,l:. i:'t'1X iLkC11
C3
Fl. . D(AX ) Q60
25.43 5CaLM-1 COMT J.d0*IJ'WA:•t ,,TSL, 50
I.,AQLYIVrA Cis► 92253
CARDtF(- T3Y TJP,&9A C:.'.A. 92007
(760)635.1010 cm" '582.3
USE OF PERMIT
CiYMMAS, Ja°C LI si2t�Lr
F31..I: G IS; .93�36y 55 -:WE, 55-334,55-320, YJ'OIA)Fd I'ARY
I; ITRUC.'111R.At, MONFICATIONS
VAIXAT'IOW 14,I100,d0 LS
PERNITI'VE9 9UMMARY
C ONST')RICT)CM FEE 101-00041114-000 W31n0
w1:IiCYHO MOTION M- RESID 101-000-241-000
�
• 11 !I
FEB 0 3 1003
v •
CITY OF LA QUINTA
FINANCE DEPT.
."t:1' 3-'I'C)'2"i11,.t°CirJ Ti Y.10� Cf. AIJl�:t�I.kN c�}IECA:FC
$154.40
. T�%95 E":�E;I'AX7.:� •NfsJi.:7
;�t3,fk1
1KXr.A.LPKRMffYEES IILIE NOW
SIM.4I
i
RECEIPT
DATE
BY, %�
D E F
ALE
INS OR
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 Aar
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 Q
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
Gas Piping
PLUMBING APPROVALS
^�
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing sinal
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
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
Low Vo( age Wiring _
Fixtures
Main Service
Sub Panels
Exterior Receptacles
"- F.I.
oke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: