0202-213 (SFD)LICENSED CONTRACTOR DECLARATION �~
I hereby affirm under penalty ofperjury that I am licensed under provisions of
Lhap�er 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
" 1
99 41310102
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:
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
po rformance of the work for which this permit is issued.
`) I have and will maintain workers' compensation insurance, as required by
,'s,' on 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 Policy No.
P.A01FIC JgMPI OYM Malt C43ON319
(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 agrep that if I should become
subject to the workers' compensation provisions ofSection 3700 of the Labor
Code, I shall forthwith comply with those prods dnS'
Date, �` ' - Applicant—
Warning:
pplicant arning: 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 s
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.
_Signa utut re, (Owner/Agent) > Date��
` iABUILDING PERMIT PERMIT#
.
DATE `� /�r VALUATION LOT i TRACT
4'. •
•••'
dug pyo ��y� y nai.
.` • e_ f .� f t �.�- ,31b.1 w y�7r7i0aL?'SY 7 f ,!!r £/Y �"f CY�'s4 X
JOB SITE `~
ADDRESS
APN
OWNER
CONTRACTOR/DESIGNER/EN INEER -
I Oil, DIZO r1_19" 19C
E,;R0THX0 19c,
PA'T.M. 'D1 ',t:T CA 92260
P,AT:'M3J1�.�+�cT CA. 92260
t;Y60)674-.9699 C'_ 1 3832'
i
USE OF PERMIT
SM) • 'f.. T 12, PJ it 's PLAN. PERIMIT i'iOES NOT INCi.,U0Z %3Y.DCK
WE L FOOL, VA OR DRIVEWAY APPROACH
CiY�TOArt C01dijTXtlIC1'Xd'11� :�2�.>)t1 o3i'
1xORC°XiPP.l TICU 442.00 Sig
GARAcTX?fGAXl.i=f RIF 752.410 3F
C0)1 TI4VUY1t394 ,ft?E ksl �t?(7Q•4 X �3�i�tX`� �3�2 4; i0
PIA14 CtIWis i - F, -000- 439 l9 $1,069,81
M ECHANl1Cl►1. 'ffX1 101-000.421.000 $ 0 6.50
ELEC),'TIZIU&L FEE 101-000-420-000 $M.4.9
PLUMBING ntEl 101.000-419-000 $ b2,50
STRONG M..OTION F Z4 „ PMI'1] 101-000-2,41-000
IMP .C'T 1119-1?
ik_4T IN PUBUO PLACPS - ?tWL .:270-f 00-443+00t7
"1Z DEPOSIT 101-000.439-3 1 S 4250.09
ftfA TUfi'J. C, ON MRU 4aTIOM AND AJA l• \J:1���13't.
[,1t'�l(.
. � �.s:i �!c �.�4���'��i;�'.f�,F'rli
�'�Fi✓�,i�W . "
RAJ
MAR 0 2002
CE D i ,k
i1Q ; t :r
BY
�` ="
D FOIA
I PEC
y
INSPECTION RECORD
OPERATION DATE INSPECTOR
H BUILDING APPROVALS
Set Backs
Forms & Footings
Slab Grade
Steel
Roof Deck
O.K. to Wrap
Framing
Insulation
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
OPERATION I DATE I INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans & Controls
I Sewer Connection
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Notice
COMMENTS:
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
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
I Pool Cover
I Sewer Connection
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Notice
COMMENTS: