0109-262 (SFD)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
tr j�• T WM161'B
y� r
Datei� Signature of ContractorE(,
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 intendad or offered for
sale (Sec. 7044, Business & Professionals Code).
( ) 1, 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. 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 0OLDEN VAOLZ RM& Policy No. W -C -M063-03
(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 4f. 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.
Date: •` . ° /%/ Applicant
. ?— 7 ,
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 havereadthis 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.
Signature (Owner/Agenvl'd Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 010J-262. TRACT
$1031070160 36 24197.3
JOB SITE .
APN
ADDRESS 79..,7%
.,' i±. D .NCE WAY
"'%X
OWNER
CONTRACTOR / DESIGNER / ENGINEER
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1C��icl�I0
C'�"0R TK0i~T.% 7WITIES'
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1 r:.11 � ;10O 41";MivET, iS1111:, AGO
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SAaalj' A RXAIWINO CA 9214108
SAW DERNARIYA 'O CA. 92408
(V09)381-wo? (MLO 2120
USE
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WALUS1, P00URA OR D ?'MAYA:PPROACK. 750.fo Pt;,pW CHECK RGR
PXi,r) fO`i.ION IVOR ISSUANCE CIP zAA0 PLAN, TYPE
TRACT CONSTRUCTION !1733.00 'JIF
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.1�4fiA'11.1L.0 SQA+ 1'7 e:1.�.. BC��Y
CONSx:PUCINOW PER 101.000.419^1900 $6$150
RUN Ct13;;ti'"K FRE 101-000-439-318 $.IS46.0A
WIlrt : M-NIt"•AL I'M 101.000.421.000 $00.00
0a•iii»420-100 $117.24
PJ:FZZ 101-000-420-000
.'T,RICA.L
PaWWM10 PRE 1014000419-000 $130100
STIM.4MOTION 1AW,-1 .�V 101-0200.241.0001 $.x0137.
:dYTTK 101-000-423-000 V0.0
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MUM FRS -PAW ,S'lG.AIS
Saw
OCT 0 5 2001
CITY OF LA QU.INTA
FINANCE: 15i _r T.
RECEIPT
DATE y d� }
: BY . /
DALED
INSPECTOR
INSPECTION (RECORD
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
Set Backs
Set Backs
Forms & Footings
Electric Bond
Slab Grade
G d 3E
Steel
Bond Beam
Roof DeckO.K.
Approval to Cover
to Wrap
Framing
Equipment Location
Insulation
Fireplace P.L.
Fireplace T.O.
Underground Electric
Party Wail Insulation 5025
Party Wail Firewall
Exterior Lath J
Drywall - Int. Lath i
OPERATION DATE INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans & Controls
Condensate Lines
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Low Voltage Wiring
Fixtures
Main Service _ }
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power I
Notice (Perm) �%�
COMMENTS:
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
Final
Gas Piping
PLUMBING APPROVALS
Waste Lines ���c�/��
Water Piping
Plumbing Top Out f _. �,
Gas Test
Electric Final
Heater Final
Plumbing Final
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection�! C'r _ >
Encapsulation
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Low Voltage Wiring
Fixtures
Main Service _ }
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power I
Notice (Perm) �%�
COMMENTS: