0301-317 (BLDG)LICENSED CONTRACTOR DECLARATION
I her ffirm under penalty of perjury that I am licensed under provisions of
Chap (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
7:331.52 E )`fit° 313110;
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 dk6liisiVe1y contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code). /
() I am exempt under Section B&P.C. fp• this eas nJ
Date i 1 1 Signature of Owner •" —! i.
WORKER'S COMPENSATION DECVA/RA ION
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:
Carver STA'I'R .kS -ND Policy No. 0460HYNIT0000415
(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 provisions of Sec7700 of the Labor
Code, I shall forthwith comply with those p'fovisiol Date: + Applicant ;r� • r -
Warning: Failure to secure Workers' Comp satior coverage is unlawf I 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 ays 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 inTecti n urposes. ,•
Signature (Owner/Agent)
- � • � Date ! ... ,- I :-2
r
BUILDING PERMIT FERMTq
03QI _S1
f
DATE VALUATION �� LOT TRACT
JOB SITE
ADDRESS �.�,D`.�.20C. A yJ.ONS-1'�.IVIERA 555-5�S
APN _
OWNER
CONTRACTOR / DESIGNER / EN (NEER
110 WE-Zr i2F;MICATIAL ASSOC, !W!
D..62.. M", :PA.+_`Ul7.0 (JD, CI?fii.. ('.C3N-'t ✓.AC' lY�'i
P.U: Box. 1060
2533 011TH COA f T: (71iin/A,Y kTf9, 250
LAQtTBTfA. C,!►. x'2253
(ryMRD:[F'H; YT14'8 ,& CA 92007
(160)635.1010 C 14
USE OF PERMIT
?'.1.9_XRkAL- BUILDING
111,003. 2-0:
11,003.:0: , ,S 55.-58. VOLUNTARY
.
TRUC1FYA gDIVYC TiOINS
VA 1#ti:1"N 110
ES".l`IMA•El1#D E`flwTf (.9F C€:)NSFIRUC1110bl'
14,00.00
P. .W. TER 91IMl Ry
CONS`flCllC"P1ON FER 101-000.416.000
STRO1140MOTION FEE'- RIWID '101-000441.000 $1.40
Q
D D
FEB 03 2003
CITY OF LA
61UINTA
FINANCE DEPT.
4
rL71I.'!'t�rAL CC1N iKtJ PiC�kJ' Ai�TI� 1•'Y Ali G`k3XtCJ[G
$+154.40
3 E133 F]?E.;PAW FM
.$0.00
TOTAL PavRMIT FRES ME.NOW
sT.MAO
RECEIPT
DATE !
BYc,
D T FIN ED
INSP R
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 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
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
_
Gas Tesi
Appliances
– --'— — , -- �-
_
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exteror Receptacles
G. F.I.
ke Detectors
" emp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: / :,13
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