0208-352 (PAT)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the BusEctess-ano%
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
DateZZ
r "?4—Signature of Contractdr_L_;&°�''� "
a 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 witti 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 8f the pffi-Perty, am exclusively contracting with licensed
contractors to construct.the project (Sec. 7044, Business & -Professionals
Code).
() I am exempt under Section B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby !affirm under penalty Cof 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.
A) ,,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 . WATX F0143D Policy No. 15,4602 -APO`' 49
(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 Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
,elDate: `67 �Zf� � ' Applicant s'��
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 4.
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; Y.
the above-mentioned property for inspection purposes. ,t
1r5i nature (Owner/A ent) Date f ”
r
BUILDING PERMIT PERMn#
DATE �,, t VALUATION LOT
JOB -SITE-- .1 l,I A �f�, -- AP� {
ADDRESS � r:; UEN�?D� tdiTre_ao
OWNER , RACTOR / DESIGNER / EN (NEER
.1 707
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USE OF PERMIT a I
520 S. A.l i MA't<+li9CJ'12 I;A!TIM. PATIO f",C3V1.,R, RER e'>ita#aLRZO ED IN.A'> S .
5 ' .
w )int EYPATIO SN'
FST IMATED CONT OF
PLAN t HKI C K RIA, 1.01X000439-318 MM
C11-1YOSTRUCTION. I?9r1 101-0i;0-418.000 996.00
STRONG MOJON FEE—UZID 1.1,1.000-7,41-000 SA
soy 'k CON& UCOTION fN PT M Cr,MCK
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CITY OF LAQuINTA
FINANCE DEPT
RECEIPT
DATE
BY
l
DA FINALED
INSP CT
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
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings
. Main Drain
iSond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
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 Cor...nection
Encapsulation
Gass?iping
Gas T't
Applia:. s
Final
COMMENTS:
Final t
Utility Notice (Gas)
„ELECTRICAL APPROVALS
Temp. PovW Pole
Undergound Conduit
Rotyh Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
Riverside County LMS
Receipt'
Receipt. Number: I0202779 Amount: 51.25
08/26/02 13:14
Payment Method:'CK Notation: 22250
Init: DA
-----------------------------------------------------------------
Permit No: BMR022083 Type: MANFRES MANUFACTURED RES. PER
Parcel No: 647-080-024
Site Address: 74711 DILLON RD
Location: TG
Total Fees:
51.25
This Payment 51.25 Total ALL Pmts:
51.25
Balance:
.00
Account Code Description
Amou_-it
100003110100072206 MOBILE HOME FEES
50.D0
657353110100020810 SMIP: RESIDENTIAL
..50
800813100200032510 BLDG LMS SURCHARGE FEES
.75