0301-318 (BLDG)LIUhNStU UUN I MAL; I UK UhULAKAI IUN
I her, -"'affirm under penalty of perjury that I am licensed under provisions of
H Chak_ i (commencing with Section 7000) of Division 3 of the Business and
CN
W Professionals Code, and my License is in full force and effect.
C) License # Lic. Class Exp. Date
W LO
733 15 2 131.110 ;01 /03
0 Z. lr� Date Signature of Contractor
co
J OWNER -BUILDER DECLARATION
UJ W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
co 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 (?xclUSively contf861ing With itcehSeO
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
c) () I am exempt under Section , B&P.0 for this reason/�
N /� Date / / '. Signature of Owner.,._. r' r
O 0)
CL Q WORKER'S COMPENSATION DECLARATION
o< CC I hereby affirm under penalty of perjury one of the following declarations:
r F O ( ) I have and will maintain a certificate of consent to self -insure for workers'
X W 9: 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 L) I have and will maintain workers' compensation insurance, as required by
O 0 Q Section 3700 of the Labor Code, for the performance of the work for which this
4 0) H permit is issued. My workers' compensation insurance carrier & policy no. are:
,It Z Carrier 37ATE FIYND Policy No. 0465 )UNItOON15
CIS 5
r` CY
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 it'l should become
subject to the workers' compensation provisionsrof S 'cti9K 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date: i /
' i1 v
r 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
& 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 fo.r inspection /rp8ses.
r I /:.1 / J
.1.1, "Signature (Owner/Agenf)' L 1,1
i
BUILDING PERMIT PERMS # I '318
1 to
DATE 4. , .
VALUATION $14,t1C .W LOT TRACT
JOB SITE
ADDRESS 1�,IXt:.�'. 21 CRA1I�1•OWN-IMERA 55' S SQ
APN -
OWNER
CONTRACTOR/DESIGNER/EN (NEER
Vill 1 itOMMTIAL. ASSOC, INC
MU, I -A PAC 51C GkN3a2,EiI.. rMC}MRA.i�``Lal
PA), 1060
353: 8011TH C OAOT Ffloil- YAY 71M. x50
LA Qi.1;i,NTA CA 92233
E"iiRi)UM BY'TIM BEAL CA 92007
(?6Uh635-1(�1f) C. L0. 5523
USE OF PERMIT
GE.,r3ET.AI..FsiJ'17,iylNG
ttC. 21:5��-fifS, 9�•32b, 9�•51d. VOLUNTARY
STRUCTURAL TUR.A1. 6AcaDIFICATIONS,
VALUATION 14,000.00 L'S
IPT1'YIYlA. WST OF C0101P I t M717 0iN
14,0W.00
PERIM 'l` P11T 9Z:T.IlodA/ARY
CO'NSTIlU(:TION FEE 101-000.41E3.OW P53.00
STRON(f MOTION -FEE - RLESI.D 101-000-241-b00 41.40
FEB 03
. I✓
CITy OF LA QUINTA
FINANCE DEPT-
Y
IYUB`•170TA'L 0— MMIRTUT1'10M AM PLAH.(';f WX
LlE L f"R�•PAD M3 `
$0.00
I`tY1AL 11MA ii' FTES DUE HOW
RECEIPT
DATE,
BY-':-.
D E FI LED
INSPEfW
�'.e f
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
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans i
O.K. for Finish Plaster
Sewer Lateral
_
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Fina!
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
emp. Use of Power
Final
Utility Notice (Perm)
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