0312-156 (MISC)LICENSED CONTRACTOR DECLARATION
PERMIT#
I hereby affirm under penalty of perjury that I am licensed under provisions of
�} - BUILDING PERMIT
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
DATE VALUATION LOT
y TRACT
Professionals Code, and my License is in full force and effect.
1 `�j • r• j �(jj71
42
28470,2
License # Lic. Class Exp. Date
JOB SITE
ADDRESS 7682 TA ,��}IG R0 TURN.
APN
770-3?**
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Jt jP �`' '� yfj_ ' (
Date Signature of ractor
Cont
OWNER
CONTRACTOR / DESIGNER / ENGINEER
,
OWNER-BUILDERDECLARATION
DTJr.Fff2LDT-MA14Cit LJ, -C
illPYit Ob4W (NEVV'DAAUPHAOMPi0A
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
I 3R6 Ham- ! l :
42 -829 C -00K S' 4304
License Law for the following reason:
:'P.Alm I)FAM:d CA, 92260
PALM DUE=
CIA 92260
( ) I, as owner of the property, or my employees with wages as their sole
C$,N 23.57
compensation, will do the work, and the structure is not intended or offered for
USE OF PERMIT
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 & ProfessionalsvCr.znAn3
Code).
() I am exempt under Section , B&P.C. for this reason
0230E� CTO'
SUP3sLEMHNN I'A.I, TO .162 TO RIEFW, CHANOV. Off' C'C�ta:'Q�f�
Date Signature of Owner
CL Q WORKER'S COMPENSATION DECLARATION
p ir 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 LL• compensation, as provided for by Section 3700 of the Labor Code, for the
Om J Q performance of the work for which this permit is issued.
Q U (s') 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
rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
' z Carrier STAIR FU14 :s Policy No. 16416&4-02 ES"TIR*7A:m 100yr or CCiri=VC;nC►N q.Ofl
J
(This section need not be completed if the permit valuation is for $100.00 or less). SUPPL�E�IiINTA:L PERMIT�?R 10 1 4*6 4,23„000 S00
( ) 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 r .
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensations provisionstof Section 3700 of the Labor
Code, I shall forthwith comply with ..those provisions. D
.� ,,Date: I?/ "-Zf ', Applicant- tf X]
`�� DEC 19 2003
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 CITY`OF LA QUINTA
of the Labor Code, interest and attorney's fees. FINANCE DEPT_
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject- io the conditions and restrictions set forth on his t
application. '
1. Each person upon whose behalf this application is made &each person at
SUB- 0T:�L CU , rUC,'T1:ON AIM PLAN 4". FW' '' $4.50
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 �5 PRRMP�r M8 S0100
& 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 '�'b'�'AL j ,�iW f ;S �j`�, K PI OW $¢,50
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 a:
construction, and hereby authorize representatives of this City to enter upon:
the above-mentioned propelrty for inspection purposes. Y �'
`. \ r ' t • RECEIPT DATE ' 2 BY 1 DATE FINALED INSPECTOR
Signature (Owner/Agent) -Date ���[�r,` f % t "l / J 7 G
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
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
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility 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:
DE.C-16-2003 TUE 11:05 AMGordonRoss FAY NO. 7603417631 P, 03
DUTF I E L D FINANCIAL,
1:)ecrnibcr 15, 2003
Cir
,y of La Quints
Building & Safety Department
V - (A l�Ac"-,I3vIlLE-
777-7011
To Whom It May CQnCCT-n:As conuictor Of Ircard for the pr"jecl,
()f L,)pccMber 19, 2003 Torn Libby Construction IL, Quint,_ The IICXV CojjtNCt0T 15
located in the Tradition Golf Co=-nun'tY
Alpha Omega license #820066.
Sincerely!
L
Ross S. Stout
Mcmber
LI I Tt IL PALM DrtSp.jj'L'. LA
42 829 coolc STRI311T. :; I I.I.
PHONJ--;: 760-568-1712 - FAX: 7 -3+1-7611