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LICENSED CONTRACTOR DECLARATION
I herp -,affirm under penalty of perjury that I am licensed under provisions of
Cha / (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 tl ).*ffo 3131/03
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).
(,,.) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Prpfessionals
Code). j /
O I am exempt under Section B&P.C. for this ea 6n/
Date /- 5 i r ' Signature of Owner.. el
1r ..
WORKER'S COMPENSATION DECLAR TION
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
Skion 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 STATE ANY) Policy No. CA601A''NITOIY09415
(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 Jjf- I should become
subject to the workers' compensation provisions of Sre ioh 3700 of the Labor
Code, I shall forthwith comply
with thos
Date: �Applicant� /provisfns.
Warning: Failure to secure Workers' Compensation coverage is un1w,(u) 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 applica ton 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 authorize representatives of this City to enter upon
the above-mentioned property for inspeotior�A,hoses.
P7
Signature (Owne—gentjDate I " 1
BUILDING PERMIT PERMIT#.
EYiUI-:4`i2
DATE VALUATION LOT TRACT'
+S14AMM
f
JOB SITE
ADDRESS 131.1W. '23 (.'•I7AMPIONS -R.I'V KRA 5✓ -,3TS
APN
OWNER
CONTRACTOR/ DESIGNER/ EN (NEER
I)_i,r4 Jw'lat' iks,4 3C., INC
:L bA..Mr R PA4:°3F C;' C%3i'N".lX11,1., C'013TV �1F.,'i`O'
P.O. DCl.)` A Cf10
x53. wtcAMI.1 COAPT YU013WAY hTf. . 250
t.�,.C1L3II�ITA r`,�► 92253
CAR:!YF T3Y J-ffl? 8 A C'.A. 92t3G'd
p 010 C' WR 51323 .
USE OF PERMIT
C3k3a2�2AT.. Zat%f.�cYA3u
f31.,W.. 25: `)S 341, S tU,ti55.334, 5f•310. VOLUNTARY
8T!?>,5i'"!'URAL MOMFIC°lA:' IONS
VAI-LIA 1'104 14,000,00 LS
K6',C1t1"M C041T OF (1101149s''fdiTl'.' IM
14,( ,00
FE"Itt"WER 91011 MARY
G()'OST—-00110A FEE 101-00041E-000 503100
STRCNO AAOTICAN FEE- RESID 101.000-211-400 $I.40
D
it
FEB 0 3 7003
CITY OF LA QUINTA
FINANCE DEPT.
: 011-`ZTcyrP d'., C161Ji$$'RDO'b'fC)W ANE) PI AM Ci: FiWIX
$1.14.40
:LMS .I RE-PAMI FE;f1.C�J'
WIN
/03
RECEIPT
DATE / I _
BY{�
D E F
ALE
INS OR
INSPECTION RECORD
OPERATION
I DATE
I INSPECTOR
OPERATION
I DATE
I 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
_
i
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
at
Gas Piping
PLUMBING APPROVALS
Gas Test --
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
_
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
-
COMMENTS -
—
Final
Utility Nonce (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)