0105-055 (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
.734094' AD I -TIC
Date Signature of Contracio,{` _�, -,
OWNER -BUILDER DECLARATION
['hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
(. ') 'l;: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. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm •Under penalty of perjury one ol�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 Policy No.
ZURICHAMWCAN
(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 pr visions.
Date: APPlican”T•,. ^5f, c --
�Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fineNp 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 -cig. his
application.
1. Each person upon whose behalf this application is made & each. per
whose request and for whose benefit work is performed under or purs
any permit issued as a result of this applicaton agrees to, & shall, ind ify
& hold harmless the City of La Quinta, its officers, agents and empl s.
2. Any permit issued as a result of this application becomes null and old 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 cancel ation.
I certify that I have read this,application and state that the above informa ion 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/Agent) i%� `' Date_''.gR�+
BUILDING PERMIT PERMIT#
DATE VALUATION ' : ',' LOT ��M6TRACT
JOB SITE a
APN 3 /b
ADDRESS
OWNER
CONTRACTOR/DESIGNER/EN 1NEER
OWMIXHt1 rr0
—
�"iv �'�°6C,C�i
2280 VIAM)L,6 W COME, SWE 150
C*ORO%i3'� C A 91720
�i,�R014A CA., 91120
(909)979.4000 C' riff 576,
USE OF PERMIT'
S.?T 3 ,. LOT 12 PLAN 41, RRihUT OYSM NOT ."iti!CLUDL:.E'L,f: CK WALL,
POOL. OR DRIV&WAYAPPROACKISIK PLAN CHFAM .R,fiDUCTIO14 K)k
M1'U r1P1.E ISr,UA14M OF U,4g ePL.lA14 TYPE
CUSTOM CONSTRUCTION %1400 SY
PORCHIPI AT3O , 454.00 SF
GA3x 4�3+.�CAYi.PORT (O3) VkAIM,30
MBWMDS:'a,+t�C'�A QF i✓Ob`Y3 IRU ry. A�x.4.✓i'.{
264,7+617M
ill"O 3 .TRUCT101411E 301,000-418-000 $1,21700
PLAN CRECK 11 FX_ 1011.000-4139-318 $26.29
M>x T;WsN JCAL FRE 101-0004M -000 $92.00
1: rx" IUC6A11 11119 101-000-420-000
1'LiM31NO ME 111.000-419-0f00 %199,75
ADfl40 ls, 103.000.423-DOO $24,00
TIM Fei:';' UCa'URE FEE 225 -000 -AAS -342 $1,997lilt
_ -
ART IN PUBLIC PLACM « R=701 -000-255-000 $100.71
M-0- - ' y 1 'RETC F1014 AND PLAN C'3 3 RON
$A,047.41
IMS P1�P FM
$1.0
MAY 1 0 2001
,�y �,a�,yr�
.Y S.Y �AL r fSel9dY.iU T YM R2Q' E' NO V'Y
TM
V4,047AI
CITY OF LA OUINTA
FINANCE DEPT
1
RECEIPT 'd
DATE . J
Aal
BY //
DATE FIN E !!'�)
INS CTO
�ti ,
OPERATION
DATE
I INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms& Footin s _
Slab Grade
Underground Ducts
Ducts
Return Air
Steel_
Roof Deck
O.K. to Wrap
Framing
Insulation
Q
/ 6&
R
NO? -6E
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
-
Party Wall Firewall
Exterior Lath
Drywall - Int.�p hh dy e
_ _
Final �� f,0
BLOCKWALL APPROVALS
Final
—
1 9 f
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
3�_ v
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
Gas Piping
Gas Test
/ /�
!!!
Pool Cover
Encapsulation
Appliances
Final
COMMENTS: J�
dl
7/ �'
Final'
2. _ _ _
Utility Notice (Gas) -�/ w�
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring.
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)