0308-088 (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
Date Signature of Contractor , �: � f'F WL_�
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).
() 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.
(A)s 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 LIBERTY MUTUAL F: Policy No. WA262DO04923012TE
(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 sh I fo hwith comply with those i I .
Date:-.. 14 e24g ApplicantI5'
1--l' 'll.
�i
Warning: Failure to secure WorkersCompensation 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 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.
Signature (Owner/Agent) r�1AMAw /Z1,01"'�-• Date 17AZ
BUILDING PERMIT PERMIT#
t��d4f3-
DATE VALE TIONLOT 6 TRACT 30357
Cf
JOB SITE
ADDRESS W-' 05 �AN0 DR.LV:
APN
OWNER
CONTRACTOR/DESIGNER/EN 1NEER
TOS.-,.37torims n'c,'
73.12) Ff=WARi1` G#100
73.121 li t)WAi2'i 00100
PALM DtT CA 92260
PAT ;M DMERT CA 9~2,60
(760)674.9699 CF: L# 3832
,USE OF PERMIT
i7Jd:I0I. FMAILY I. -. .U.+W1'1�7
-
SPD a LOT 60, SP!'30NAFfl.-P9§LMIT DOES NOT INCLUDE BLOCK
WA;LM P601. SPA OR, DRIVEWAY APPROACH
CUSTOM CONSTRU' C OON 2,800.110 8F
PORC kYPA'f IO - 075.00 Sly
03 kRA E CARiPORT 610.00 a
EST 1211 C067 OF C0XSrRU(7 r10N
2—V,733—W
Pry' m sum"im
CONSTRUCTION FRE, 101.000-418.000 81,10s.59
PLAN CHECK FEE 101-006-439-318 $900.00
.
MECHANICAL FEE 101.000.421-000 5111154
L? ECTRfCALI+'FZ 1101-000-420-1000 $ISG.iQ►
PLUMBING F9E $1,84,00
STfi0ldG MOTION FES - USID 101-000-241..000. $23.37
01 ADTNO PC,E 101.000.423.000 $1:4,00
DEVELOPER IMPACT FEB.
ART IN PUBLIC. PLACID it.LME 2751.000.445�000 $84,3'
ff _T COITS .tt.TTCI.100 AND P3.A1~i
T:� S T�IZZE-1? 3
$0,,00
SEP 2 6 2003
CITY OF LA QUINTA
FINANCE DEPT
RECEIPT
DATE
BY
04
D D✓ SPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts 42,41
Slab Grade
It ju
Return Air
Steel
Combustion Air
Roof DeckExhaust
Fans
O.K. to Wrap
_
F.A.U.
Framing
Compressor l
Insulation
_
Vents /
Fireplace P.L.
_
Grills
Fireplace T.O.
Fans & Controls
Party Wail Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
_
Drywall - Int. Lath
Final '—
Final t'
POOLS - SPAS
BLOCKWALL APPRO AL
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Ptbg. Test
Final
Gas Piping
PLUMBING PVAL
Gas Test
77
Electric Final
Waste Lines
Heater Final
Water Piping
.K
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer. Connection
Encapsulation
Gas Piping
Gas Test
Apprances
Final
COMMENTS:
Final
Utility Notice(Gas)
ELECTRICAL APPROVALS.
Temp. Power Pole
Underground Wiring Conduit
Rough
Rough Wiring
Low Voltage Wiring
Furfures
Main Service
Sub Panels
_
!
Exterior Receptacles.
—
G:F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
— V,