0402-042 (RPL)LICENSED CONTRACTOR DECLARATION .r„.�,.a s4
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 Businessand
Professionals Code, and my License is in full force andteffect.
License 69742 �c. Class
y^ Exp. D 1b/3.I/U!
Date Signature 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:
( ) 1, 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).
( ) 1, 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 Myworkers' compensation insurance car &policy no. are:
Carrier 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,
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 o_f-Sectioo 3700 of the Labor
Code'
'I shall forthwith comply with those provisions.
'Date: 1 ] 2-41 Applicant -
'57
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.
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 forliinsp inspect—ion
Uposes.
Signature (Owner/Agefrt). _ �- �" _ Date .�"%1"0 It
1,s
�= ' -BUILDING PERMIT 04(2-042
DATE r VALUATION �r y>� LOT TRACT
JOB SITE 7'%-411 0 CA1i,1'X TETAMMCa37E A
APN •• -
ADDRESS
OWN9E�Ri
CONTRAyCTTOORRiy/DESIGNER 1NEER
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53,875 A 1'i)AMA171cRJ
LAQUUTIA. CA, 92253
Y.,AQLTI-WfA CA. 92M
060)771.3362 CIRW 5954
USE OF PERMIT
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43K.-IbI,A, 7'�•I; .61�("�P TIC3IsY, 135 S,, }7 $1 HK B(A)CKWALL (CwT
STAN OARD)
3 FT. WALL MOD 1.F
d'OOLANWORSPa'1. 10„600.00 LS
'lUAIMP COS' OF COM rM4JMON
3.2,944.49
Pi MaJAa'1OF!'. SUMMARY
P6%N CHECK F&is 101.000-439.318 $93.60
COINSTRUC IC114 FEE 101 -000 -418 -Wo $144.00
MECHANICAL ME -- 'POOL 101-000-421-000 $24,"
ELECTRICAL, , FZZ •- POOL, 101-000-420-000 $45.00
PLUM40 FKF -- POOL 101.000.419.000
PFFEB
13 2004
CITY OF LA QUINTA
FINANCE DEPT.
SUB -'DOTAL CC2a:'i' RUCTION .AMD rIANT C1_.K
1:2.33 PRE -PAM MIMI
T07AT..PE-t89T YEFS DUE NOW
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RECEIPT
DATE -+,
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BY/ :
DATE FIN ED
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INSPEC
.
—
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
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
d
Set Backs -
Electric Bond
Footings
Main Drain
Bond Beam -
Approval to Cover
Equipment Location
Underground Electric
, O
Underground Pibg, 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
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
L
Gas Piping
Gas Test
Appliances
Final
p v
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Furfures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
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P.O. BOX 450
LA QUMTA, CA 92253
PRONE: (760) 564.1866 FAX. (760) 5612627
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PRONE: (760) 564.1866 FAX. (760) 5612627
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