0301-314 (BLDG)LI(:tNbLU UUN I HAL; I UK ULULARAI-IUN
I her firm upder 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
733 15 2 �+ 1 aC 381 iO3
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).
(,e-) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 704.4, Business & i?rgfessionals
Code).0/
(') 1 am exempt under Section B&P.C. or this re aon
Date ! "'') ''. 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.
(X) 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-11iRd'D Policy No. 0001UNIT0009414
(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 should become
subject to the workers' compensation provi ions of Secti n 3700 of the Labor
Code,'I shall forthwith comply with those p�vision
Date: r r.. Applicant—
Warning:
pplicant t. :...... _-
Warning: Failure to secure Workers' Compen ation coverage is unlawfdf 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 irs relating to the building
construction, and hereby authorize representativee,s of this City to enter upon
the above-mentioned property Inspectiourpdses.
Signature (Owner/Agent) ----71-./7 !`Date
BUILDING PERMIT PERMIT#
�Y '��
DATEQ./ VALUATION LOT TRACT
.
JOB SITE
ADDRESS 1%D0. 1.7 CMA1V 10ANN-RI!/'1tM-4 55 ' 70(
APN
-
OWNER
CONTRACTOR / DESIGNER / EN &NEER
PGA WF8f ]x1R3WYf. "TtAi. ASSOC., IRC
DE., MAR PACIFIC" (1ENI RIU, CO',' TELAC.' 1
:F^,O. BOX ) 060
2533 SOX II COPAST F T011WAY 017 250
LA Qi'lMT A CA -02253
CdtK0LFF 8Y `ICH.E•D. 2rR A 92007
f;60 35.1010 C 14i 5B2.3
USE OF PERMIT
OF".R.Al.-
FILD(L 173S•?3tt, ;S•112I,, S 7�55.64e1, itOLDi93'A3:Y
STRUCT URAL 9AODIV1CAT15A S
VALUATION 14,0NU.00 LS
1 XftNffr FEE S$3MMARY
C ONk"'RUC T 1ON FU )01-000-4.18-000 $133.04
1J ii•Icci140 MOTION IZFw810 1611-000-2414DOO $1.40
D Q 0
FEB 0 3 2003
CITY OF LA
61UINTA
FINANCE DEPT.
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1MAL P—V"ft� M81DITs POW
RECEIPT
DATEI
BY•=���
DA IN ED
IN TOR
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 Conoection
Encapsulation
Gas Pipino
Gas Test
Appliances
Final
—
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
r
Temp. Pourer Pole
Underground Conduit
Rough Wiring
Low Voitabe Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
,G.F.I.
oke Detectors
emp. Use of Power
Final
Utility Notice (Perm)
/COMMENT :
LU /