0301-314 (BLDG)LICENSED CONTRACTOR DECLARATION
I her Irm under penalty of perjury that I am licensed under provisions of
Chapw(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
233132 B IAC, 7r)1,t03
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 & Professionals
Code). !/
(>) I am exempt under Section , B&P.C.ifor this rea on/
Date 1 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 STATE M14D Policy No. 04601UNITOOM15
(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 1` should become
subject to the workers' compensation provisions of Secti n 3700 of the Labor
Code, I shall forthwith comply with those p�fo visions/
Date: } :i I Applicant 1. �'
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 representativ � of this City to enter upon
the above-mentioned property for inspection pu/rp� ses.
�YSignature (OwnerlAgent)'' - Y� ) 'Dater
• BUILDING PERMIT PERMIT#
0301-314
DATE VALUATIONLOT TRACT
�� 4,it�3.ClQ
JOB SITE
ADDRESS .i✓�j��i�0.a. 17 C: I1 i - VJUZ ZA �S' (o 4
APN
OWNER
CONTRACTOR/DESIGNER/EN INFER
PGAAWLEW'R .SWMM 7 MISOC., IRC
)DI;T, MAR. PA 1C rWNEILAIx C'L'X!1`S1:t.A(..f01
P-101 BOX )w
:2533 SOUTH C OMT 111011+ AY S`M 2.510
1;. AQUWA CA. 922.13
CAS: BY'n f' BRA
CA 920071
CDLIN 3823
USE OF PERMIT
tai+,R.A�. �CITg �Ia+i�
iil.1:}CF. 1`7: SS•:'�p, r�•'iT� r.S•'70ti, �„i•f9R. V'ULaN`I'Afi`I
S1'1t13t'-'1"URAL MOPId�KA'� fUN3
V.ALUAT10N 14,00,00 W
PKRINUT Vim SUMMARY
CON8121ICTION FU, 101.000.4141.000 $153.0
ST�CINS� 109C1I'10N1 H"�• i�.41C1 1C?1-{i�JCk.�g1-(l(DE �1.�
NtFEB Q 0 3 2003
OF LAUINTA
NANCE DEPT.
S1Y14.-.T(3'rAL CCiNSTRI)MOI .Aims.) PI,A)l 01 W"m
$154.40
'1'A13J:.1'ERMM M14 DCS NOW
t1*54.40
RECEIPT
DATE; 1V
BYs-
DA IN ED
IN
TOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
IF
MECHANICAL APPROVALS
Backs
Underground Ducts
ms & Footings
Ducts
Slab Grade
Return Air
Steel j
Combustion Air
Roof Deck j
Exhaust Fans
O.K. to Wrap I
F.A.U.
Framing j
Compressor
Insulation j
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation j
Condensate Lines
Party Wall Firewall
Exterior Lath I
Drywall - Int. Lath j
Final
Final I
BL CKWALL APPROVALS
POOLS -SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
nal
Gas Piping
PIJUMBING APPROVALS
i
Gas Test
Electric Final
Waste Lines j
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
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F I
rloke Detectors
—emp. Use of Power
Final
Utility Notice (Perm)
COMMENT
Go�r,ll s� 6�9/3�