0402-022 (SFD)LICENSED CONTRACTOR DECLARATION
I herebyaffirm 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
7E$ aU P.1 C:1tiY1C
ate � - t o "�' Signature of Contractor—
OWNER-BUILDER
ontractor 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
Section'3700.of the Labor Code, for the performance of the work for which this
permit is issued. My workers' compensationIinsurance carrier & policy no. are:
Carrier Policy No.
EntmPT
(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 provisionsof Secti • n 700 of the Labor
Code, I shall forthwith comply with those -provisions.
Date:6'�!Applicant?�
vim..
Warning: Failure to secure Workers)'Compens'ation coverage is unlawful and
shall subject an employer to criminalrpenalties 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 aind'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.
ignature (Owner/Agent) � Date
-=:BU_ILDIERMIT PERMIT# ;
DATE ' ~VALUATION LOT 0402-02-2 TRACT ~'
�..:. 29147.1
JOB SITE
APN
ADDRESS S2-0704191 IM. XC(X11X1WXS
7161-820-W7
OWNER
CONTRACTOR / DESIGNER / EN INEER'
W kOPT, i?.P+at iI-WF10 1, LLC
XMLM ;A C09VrRU1';110N DTC � r =
BI- 07 0 CH19.1�'.lAi LFER
7€I.070 CAMI,
L& C TMUA C„ A 927,,53
LA Q:u .A CA. 92253
(769.)56,4.4832 CB.V 3237
USE OF PERMIT
antG e Pxh4.IY.,'.f Dldr`.C,i.:4,•]]cTC1
STT) • 1,0T7, PLAN 6. PERMIT DORS NO t' 113C:I, UDZ BLOC I(WA,LLA
P001,5 $PA. ORDRIVEWAYWPPROACH. 75% MUC a ION TO P.L& CHRcy.
FKF VJ1,r ". 0 MUL'i1;PI. E ISSUA14C E, LIP S.AMM, PL&14 TY'PB
CUSTOM CONSTRUCTION 30I2100 V
PORC,'FI/PNT10 9113.00 SF
C11ii.1�G33�1tvPiP't�3t`C 996.00 `P
X`sru"TLID CON'r or r0NIVI TICrIDN
30fb W?AO
C.'ONSTRUCTIOX . E 101-030.418-000 a),364.40
PL&N CHECK F12, 1.01-000-439-:31.8 STA.95
MECHANICAL FER 101-000.421-400 $162.50
ELECTRICAL 101-00042"00 0210.:14
FL'UMBINCI FYIE 101.040-419b000 W111.73
ST,RONO MOTION PEE • RI{:3:D 101440-24.1 -000 $30.0
ORADING FEE 101.000.423„4130 $15.00
D V Y,1D V_h1, IMPACT I $2,40100
PidWISE.PIAN - 101"000441-M $100.00
ART TIS PUBLIC'. PLACES - RESIL 270-000-445-000 3266.02
STMI -'AOTAL COA1'S'ERUCITIOW AND PURI C.WWK.3,019.OS
e =93 PRE-11,AM TrEW
$0.00
D
0rTAL',P10M3PrFM. DUE NOW
",Q] 9M
FEB 10 2004 ' '
CITY OF LA QUINTA
FINANCE`DEPT
RECEIPT
DATE,.
4. 1
F
BY �f,�/
DATE F N ED
l
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 d
Exhaust Fans
_
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation a o
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
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
Water Piping
Heater Final
Plumbing Final
Plumbing Top Out 61
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test l c
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) C
COMMENT,A�� � y3j/y
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