0301-321 (BLDG)LICENSED CONTRACTOR DECLARATION
I her'sffirm under penalty of perjury that I am licensed under provisions of
Chaff.! (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
733 15 2 B 'RIC" 3/11/03
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).
(� ,) 1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
() I am exempt under Section B&P"C.1lor this%re 4l�
Date i .. d Signature of Owner .... j1. -
WORKER'S COMPENSATION DECLARATIONYr T
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.
Y") 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 ST.ATF i+111<M Policy No. 04601U*NJTffil0HI5
(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 th t if I should become
subject to the workers' compensation ?rovisions. of 0 Ion 3700 of the Labor,
Code, I shall forthwith comply with thoee
;.• provision
Date: Applicant',_ -.../,A—%,(-
4
Warning: Failure to secure Workers' Corpl5ensation coverage is unlawfu)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.
I certify that 1 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) r �,'` i` Date
• i� 5 r
BUILDING PERMIT PERMIT#
(1�-a+�
DATE ' VALUATION U4,WjOA')o LOT TRACT
.•0
�; ,3
JOB SITE
ADDRESS DIAX). 24 C,1 .AW. IONS-1iPx."VMR.4 ��. T �1 /_
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
TQC#AVfEff.fZEME -IML ANOC., INC
DIM, MAR PAO-0-10 CIMFMAL CONTX�VMYi
P.O. BOX 1060—
153:3 Sf Un1 C(3A..,Tr1U(?;i WKf NK 250
LA QUNTA CA 92253
C.A:Cd.TVr1?BY3Tf[tSEA CA 'f1=i
✓v`160)635-1010 Milo 51M
USE OF PERMIT
8L.D0. 24: 55AI4, 55.411.1„ 55.400. V014Lri+fTARY
STRUC" PURA1. MODIF'1('.f►'HOWS
VALUATION L-
X`.4VEJdYatld.HD COM' UY C2;1NM,UC"i IOR
�'Vo4lR71J.f.�ll�
lrii".t�.wf i!`1: E NUI LURY
MNSTRUCTION lr`U 101 -OCKI-4 18-000 $153,00
VROWOMOTION ng • 1dMID 101•006-241-000 $1.40
CIT' OF LA QUINSA
FIN CE DEPT.
21.03 Mt C':(_)WM_,7TCrr!0X AND P.L.AX t`.tiF IX. '
$134.40
11,01D PRE -PAID
IMAL Plffdfff F17% DUE NOW
$1 N4,40
RECEIPT
DATE j
BY l"'
DA
I INSPEWR
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 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 POOLS - SPAS
BLOCKWALL APPROVALS steel —
Set Backs Electric Bond
Footings Main Drain
Bond Beam Approval to Cover
Equipment Location
Underground Electric i
Underground PIN. Test
al Gas Piping
PLUMBING APPROVALS GElas7est
ectric Final
Waste Lines Heater Final
Water Piping i Plumbing Final
Plumbing Top Out Equipment Enclosure
Shower Pans O.K. for Finish Plaster
Seaver Lateral Pooi Cover
Sewer Connection T Encapsulation
Gas Piping
'Gas Test
Appliances
Final
COMMENTS:
Final
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 f
Final
Utility Notice (Perm)