0301-258 (RR)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 p
55500 ' C39B
Date '� WSi nature of Contractor
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.
(�) I have and will maintain workers' compensation insurance, as required by
RSection 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 gX} MP7' Policy No.
(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,
Ifshall 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 provisions. '
Date: i r� Applicant, .4•r. .awew. •, ..G1-•tt.. f
Warning: Failure to secure Workers' Compensation coverage is unlamu' 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 representa+tives of this City to enter upon
the above-mentioned property for inspection purposes.
J / .n
Signature (Owner/Agents �¢-+1^�''' 6 � *�*- � 0940ate 1 :2 r
P'
BUILDING PERMIT PERMIT /1
'-. 'F3
DATE t VALUATION +�nranr.� LOT TRACT
JOB SITE
ADDRESS 54,W-'AWIMA M O
APN µ
OWN�EjyR�
CONTRACTOR DESIGNER ENGINEER
yLiJSSLAI7%RLCICOgAy8
AyDA/KkAAry
54-570
370gJSAA.1/AVF,,
:F^A QV'.FA7'rA ak 92253
UM10 CA. 922"01
(76( )776-0373 CTIA 2201
USE OF PERMIT
RVROOT -WJTH 5HtYVC9L.fiA CLASS "A" to ATE.fed.A1Z
VALUATION �040.OD F�,Y
RMWX= COST @. F CONSTRUCTION
2,%',*.W
P ' AW M SUIV04ARY
R.EROOF FEE 101-000-4-18-000 00.00
p _n �l
JAN 2 2 2003
CITY OF
LA QUINTA
FINANCE DEPT.
31.7`,k -TOTAL CON MA UM'109 AND MAN C—TWA?',.
$30.00
1. M11119 PRE -:PA 'k ..
r
0.00
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
IMSPECTION RECORD
OPERATION
DATE'
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS.
MECHANICAL 4PPROVALS
SetBacks
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
OX 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
BLOCKWALL APPROVALS
POOLS -SPAS
Steel
Set Backs
Electric Bond
Foobngs
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUM BING APPROVALS
Gas Test
Electric Final
W, aste Lines
Heater Final
ater Piping
Plumbing Final
tfumbing Top Out
Equipment Enclosure
_�hc�A r �Pans
O.K. for Finish Plaster
Sewer Latet&.'
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
"Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL 'APPROVALS
T
emp. Power Pole
�,A,Jnderground Conduit
,Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
SOb'Pariels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)'
COMMENTS:
onN�LC70a1�rYrrRar'htY.+au4i4o�t4ttagyoyttlnYh
State Lic. 9586470HENS
�(
INDIO, 0ALmoFmA-9680
(700) 3424406
V.M. (780) 770.0373
Ono p 0 '1111
AWE
`Aft ramoom is ewr4nteed to so, as apeathed. All WOO, to oe aomo"d in a�w0for"AnllMe ,.
mtruter ace4"drne to SU"Wd ON01 e. Any 4tterabon or deviatten f -an 410sve e2a418ea• Autriotiied
turns 4ne4tvMt vat. will be taeaaA ay uian vrtlen orders, enNlf "ene aM P.
extra c4afte prM arta OW in* *%"Moto. All ieraer tnts ""baht" 4Pen att;ltay, 4044Gnts
of 9ateye oeyand our t•On401. Owner to cater lat. tornatso One other ne4wsary 1nU14nc4i•Note: 1'nii:prOpoial mey be
OW erW"m ore tufty Covered by Watkrnan•s Compensation Msµfanas w;thgrawn by u3;af i*, vocoptld within days
JA1X $ tW Ut jit"0941- tine nave pricali, $06clftcaklops
and canditiona are sabafectotyt w4 are hemby accftmd. Ycu Am autherintt t�lar?esarR
t8 do the WOO as speotfied• Payment will be mads as outitnod aOtave.
Oete of Ac+:eptanim. 5i�nptu►e ,.,,