0303-182 (MISC)LICENSED CONTRACTOR DECLARATION
Thereby 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
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that'l 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
p.,l am exempt under Section , B&P.C. for this reason
'Date ,f/ ' Signature of Ownerf �•� - • -_
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 Policy No.
(This section need not be completed if the permit valuation is for $100.00 or less).
If.) I certify that in the performance of the work for which this permit is issued,
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„l shall forthwith comply with those provisions:
Date: ” i; , ., ApplicM4Xl"' �------
t t
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 Buildind 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 autthorizd representatives of this City to enter upon
the above-mentioned proper y ori nspectiori'purposes.
Signature (Owner/Agent") ` ` C - -^ Date'
PERMIT #
BUILDING PERMIT
rF MY30 W1
DATE D �+ t i VALUAT'ON LP�� L TRACT
IV S.00 3 28034
JOB SITEg�
APN
ADDRESS
S�V�eJii3
OWNER
OWNER
-1
CONTRACTOR /DESIGNER / EN INFER
rmb&r Luz,
OWNER 1. UMI1>MZ
.3.35v MM GM0431)ME EAST
PAT M 1GWS T. CA. 92260
USE OF PERMIT
OV Flt-EXC;,;3VATICi'N 01? WT 3 ik.WD IYI?.'ESTAIMISM411?'NT OF..APPROV.11,1S
COMPACTED PAWLESH THAN 100 CUBIC X.,49;,.&
WS7i' I- AI'ND COST OF COl'i'S'MAXII-TY10N
Rwr FRE Mt May
ORADINO FEE 101-000.423-000 S21150
D AA D
MAR 17 1003`
v
CITY OF LA QUINTA
FINANCE DEPT
S(M-TOTAL CORM-RUC13014 MD PLM CkLCK
$22.111
SS .Y 1PAXD I''3
$0.00
,I 0TAL.PYYMT FFXS DI Ott' 14 Ow
RECEIPT
DATE f� i r�
BY
DATE FINALED
INSPECTOR
�r.
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 ,r --oY, 119POOLS-SPAS
BLOCKWALL APPROVAL
Final
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
WatercRiping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sew*, Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Rility Notice (Gas)
ELECTRICAL APPROVALS
w 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)
COMMENTS:
City of La u inia
Developers PM -10 Approval Form
Prior to the issuance of a Demolition Permit for the project listed below, Public Works'
I
approval must be obtained. Please return this form to the Building and Safety Department
only after approval. .
Project Address: V J— S20 v TH L(Y L ANr t. i �; Tit..
Scope Of Work: (, z %1
zhr6)C� Pnx cJ"-r,F-2 ?2-he-
6)
pN, ,� 1,; d Le- Cti 403
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C OY �A-2,/' �4 �/ l SDS Dlz t��7 ��►�
Public Works Department App r val is Hereby granted:
• II r
o Freeland, Senior Engineer Dat
A
.14 '
• February 25, 2003
City .of La Quinta
Public Works Department
To Whom It May Concern:
We are in the process of trying to build a custom home in south La Quinta. This process
started in October, 2002, when we sold our old home in. La .Quinta Fairways. Since then
we have been living in, our motorhome with our two cats &: a 65 pound yellow lab. The
process .of drawing plans, structural engineering, and so forth has far. exceeded our,
anticipated time line. It would be greatly appreciated if a speedy process could take place
in your offices so we may proceed to actually begin building.
Thank you in advance for your consideration,
Denni &Meg Lee
Outdoor Res rts
'80-394 Ave 48, Lot 380
Indio, Ca. 92201
(760)285-2683