0401-421 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
04 W Professionals Code, and my License is in full force and effect.
O =) ch License # Lic. Class Exp. Date
r`CY in
r— W r- 129i')1 D , 1MUM
It
Z r Date,.% �-• t Signature of Contractor t '£ J i-
coO�/
J U 0 OWNER -BUILDER DECLARATION
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ License Law for the following reason:
Z_ ( ) 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).
co () I am exempt under Section , B&P.C. for this reason
IJ7
N Date Signature of Owner
ON
d Q WORKER'S COMPENSATION DECLARATION
p cc I hereby affirm under penalty of perjury one of the following declarations:
Lo H p () 1 have and will maintain a certificate of consent to self -insure for workers'
X W L= compensation, as provided for by Section 3700 of the Labor Code, for the
mJ Q performance of the work for which this permit is issued.
Q C) (.,)` I have and will maintain workers' compensation insurance, as required by
p Q Section 3700 of the Labor Code, for the performance of the work for which this
Il H permit is issued. My workers' compensation insurance carrier & policy no. are:
Z Carrier Policy No.
00 --) STATE FUNI.) 229- 0919'98'7-2003
r` CY
Q (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
161 Code, 1 shall forthwith comply with those provisions. t �,
,-Date: .' al Applicant -�" ��' _
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.
44
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) 4,R ! Date / G
'�O"BOILDING PERMIT PERMIT#
DATE VALUATION LOT 04,1_421 TRACT
/ SI2,�1tX(1,f3
JOB SITE
APN
ADDRESS .3:593 liYMDA. VE1.ASC 3
M `
OWNER
CONTRACTOR / DESIGNER / ENGINEER
110"W ;14 FWANCH,
DAVID L 2'1M)It+tC:#,jC N
P, 0,11O X 134
41-7 801VEMMUAGE DF:
LA Q INTA. CA. 92M
BERMUDA ]YON 0 CA 92201
(760Y.08-7526 CRIR 3724
USE OF PERMIT
POOL AND OR MAA
POOUSPA.. ALARMSMARRIERS .HALL HE IN P1...ACZ A'1' PRII-P ASTFR
11TOPFCTIO14I, P.'tl'1.11 AKH F L}JO1A iJ i? NOT INCLUDED
1*00L.AND/OR SPA 1ZM. go 11.13
1<t:b" u"TI'D COW t: r C0.14SS.'.FitlMON
WW.00
i'TRUT4' 1+'3t E NUMARY
Y%'i.K)q CITECK FIE 101.000.439.318 187.73
CONST RUC',10N PW_E 101 -OW -418-000
MECHANICAL FEE -- POOL 101.000.421-000 $24,00
ZLYC'TRICAL FPW —FOOL 101.000.420-000 $45.00
PIAIRIBlN0 FFF -• 1001, 1011n-MO.4'19.000 MOO
iJ
JAN 3 0 2004
Ci'r: C: _ j � ; rA
F j'T.
STIB-1YJ'1'AT CONS 1`1t7.TG"`r,[ON ASD laLf ter MWIC
1l XV 3 M -P AMD rlbsd
$0,0D
TOTAL FSR ]DUE NOW
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
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
Final
POOLS - SPAS
BLOCKWALL APPROVAL'S
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
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
G'`v f�KJ
Final
Utility Notice (Gas)
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)
I HIGH�POINT '
I
W-0. HIGH _ -- —A— 5'.0"" HIGH LLbOD. FENCE - r I .. ..
17.IIe wvo0 FENCE
i MIN.
GRAVEL
I% — -- — AO
I— 7.4.
AC CONDENSER SET — --
I _ ON d'Xd' CCWC:.3 49-1
PAD1
TOP OF FAC) i
I • I X6' PA NO LESS THAN 3" + I
ABOVE GRADIi
'I E• ) — — I hASTER EIED13J0!•1 r•0• N.o•
w PAD
u I
4 GRkVEL II CLOSET — — — —
77
--
.. I R:A
GVEL P
LIy!NG ROCM
• S'-0° HIGH —•.• - I
.WOOD FENCE
n
I— ia?OROIx1 3
I, a
�' • - I
FAMILYRaOM
� a,k4lryo
5'-0' NIGH I — i CQNC
BLOCK WALL
x6' PA 1•-CARIrBEiB(aE IENTRYT
%oseSl? \
O _
A.
I
ILLUMINATED STREET HU'15ERS
VISIBLE AND LEGIBLE FROM
.. - THE STREET -
GRAVEL
W I �Q•� 15.o"GaLLuIF!30Par tact — —
4 . M 62" LE6' 6PAC!NO
>9 3N" DIAMETER
�' T'.Im+ 1EN31N
Cc
314
'-3" MEIGWTO. WTWOOD
t
` Y-01 HI H --w
Pn BLOCK WALL.
.
DRIVEWAY APPROACII REQUIRES A,°
SEPERATE PEWIT AND INSPECTION
FROM CITY OF LA QUINTA PUBLICldC
- WOS DEPARTMENT.•
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