0312-002 (BLCK)LICENSED CONTRACTOR DECLARATION
U) I hereby affirm under penalty of perjury that I am licensed under provisions of
F_ Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
CNI W Profe-.,sionals Code, and my License is in full force and effect.
O =) ch License # Lic. Class Exp. Date
I Lu lY 469%42
oZ y,Date a-1-03 Signature of Contracto. - — _ ~"
(OLlze
J U C) OWNER -BUILDER DECLARATION
W W r- I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ U) 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).
C'') () I am exempt under Section B&P.C. for this reason
N Date Signature of Owner
OC\1
CL Q WORKER'S COMPENSATION DECLARATION
p cr I hereby affirm under penalty of perjury one of the following declarations:
Lo � O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W !�= compensation, as provided for by Section 3700 of the Labor'Code, for the
O � Q performance of the work for which this permit is issued.
co Q C) X) I have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
Il rn F- permit is issued. My workers' compensation insurance carrier & policy no. are:
1�t z Carver ;FATE FUN,,) Policy No.
w� 1744856-0.11744856-0.1
r -O
J(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 tshould become
subject to the workers' compensatiaMpr v isions ot"Secti 3700 of the Labor
Code; lhlal'forth ith comply wit hose) • r visions. ��
/Date: rj , 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.
n.
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 represp atives of this City to enter upon
the above-mentioned property or ilispection p Poses.
� tt
*''Signature (Owner/Agent) j Date la-'- 3
BUILDING PERMIT PERMIT#
ro.
V 7'a^1.7W.4'i
DATE VALUATION LOT TRACT
IMMIX 12 RI.,.TC 292
JOB SITE
APN
ADDRESS 77-710 C:ALLF, T:OWWWA
-774-2.52,02.2
OWNER
CONTRACTOR/ DESIGNER / EN INEER
MUCK I?A.°ifID SOX
ERICX� DAV17SON
53.875 AVMDAMA1 ERID
53-875 .A.gii°..AiIDAMAL)I.1Z0
1A QUINTA CA 922.53
LA QI%D+3"i."A CA 92233
k-760}771.3362 CBI.# 5954
USE OF PERMIT
GRMINAL DIMMING
100 LF C0MTiI d k7ION T RZT AININO WITH 6' GtARLIEN WALL PER. CITY
STANDARD ALONG 1 ID9 W6,2001 CAG.
6 rfi.'N ALL 1510.00 LF
EMMA= COST OF COMIRUL',Y'.1[ON
21,500M
PER ATT r, EE 1rI'rA+1il19f:ALRY
CONSTRUCTION FEE, 101.000-418.0001 $54.00
3tJ}3� �,t1T,. C�,QI.�'a3i."f�ilL"TIC.��S A.J�'D F'Y..�1►`�' C.�G`K
�ia�:.t30
U33 PRE-PPaD M33
$0.00
y, ._----- ; I, a STA ?KRMr F7MG DUE NOW
$154.00
�3
L111
RECEIPT
DATE
✓
BY t
1
DATE FINALED ' �L
INSPECT
aof
W
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Stab 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
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
12 Aug ft5j7
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 Connexion
Encapsulation
Gas Piping
Gas Test
Appliances
f.
Final
Final
UtiCdy 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)
COMMENTS: