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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 Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
533670 B hic 6130104
Date'`- / 't ` 02 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). 11
( ) I am exempt under Section , B&P.C. for this reason
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.
( ) 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 IJTl TF, FUNT Policy No. M0462-011
(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 thos"e probisiops.
n
Date: a r 2 a7 Applicant—
Warning:
pplicant `
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 s
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, indemnity
& 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 for inspection purposes.
wy
Signature (Owner/Agent) ' %� `' "' �-^'~ - •• Date '
BUILDING PERMIT - PERMIT#
0210-074
DATE VALUATION LOT TRACT
-S„,
9 30125.2
JOB SITE
ADDRESS 77-770 CONCTIA MU
f
APN
773 -022 -
OWNER
CONTRACTOR/DESIGNER/EN (NEER
�:C.3�?A%R.HC)M'M THC
SEMOS; CORPOW1014
77pp-qq:�g9fr�A4yy�•�:��°'aaO��1Iyy%iTRY• CL D�iM Si3'1'qq"1.iEy 137
77-,�6'`p�r}5•�}1--��y,,��C��VVSs���INnRY C�.iU�3 DRIVE SUITE 150
Pflh�lOSS,lJJu�� W CA, 92211
PAh7,�1A9./.Y..il'P, Yr CA 92260
(76OP72.8224 L BL*l 1131
USE OF PERMIT
d' IX 1+M.Lli.:Y" DrAi'1r Cai I t3
SID - LOT 9, PLAN 3Rd PERM9T 00FIS, NCYC INCL I)DE BLOCK WALLS,
S,
P0014 SPA OR DRMWAYAPPROACfL 15% 93;1? AICA ION '.(.;i PLAN C""# ECV,.
FYZ DUE 'I O ML;L'k'1P.1E I&SUPMC;}:OF SAAAWIK1'1.N!1.2i TYPIL
C 13311 C M C".ON�'.�TIVI Iw710N Z7410 BY
PC.?YtMP.ATIO 216.00 Si'
GARAc39T�fC.'AIU10P.T 33a.0 Sit
Era d'IPJAiED COITT ('YF C ONSO'rFd.0 .ID"ON
PY.R T Vice' '. $��`�Wi URY
00140 T ItUaw'I'.ION T%R 'i 01 -000,418-000 $1,094.0
PLAN CHECK �F,1'11 101-000.4394111 $214.60
Sd�%r_ 1A:NICA],F1<1 101.000.421.000 $107.50
li:f.=TRJC;AJ1YBIP 109-000.4-20-fi(l $139,80
P)�i91 k 9N0FRE 109-000.419•OOD $02.215
S`TRf�Idit1*i1G3'iUS+llt i3� LS9'U 109 -WD -241•.000 Milds
ti_R.A.DINO FEE 101 -000 4e a-000 $15,09
r)WE,' -OPUI IMMCT ME $2,+9®s.OR
ART id PUBLIC PL,,A.CFAS - RE -91L 270 -MO -445.000 $66.3'
8TTB-. TCrYAL C`c' XY TCUCIT.OH AM :F'I.AN C7tUfi
$4,22,T-15
1
tRili
u OCT 17 2002cr
SIE ^'^z �'%�r1i''DATE'S+1"
; 1,
BYi�/�
DATEFINA7LED
INSPECTOR,
s.i
A�.
AM'
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
-2,
Exhaust Fans
O.K. to Wrap
r
F.A.U.
Framing
Compressor
Insulation
v
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
- 3
Drywall - Int. Lath
LIE
Final
Final — - �S
SLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond 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
iL / J
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
_
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
_
Appliances
Final
Final f7_ -
Utility Notice (Gas)
. ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit .
Rough Wiring
Law Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final 7 -
Utility Noticg (Perm) - - '5
COMMENTS: