0205-134 (PAT)LICENSED CONTRACTOR DECLARATION
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 Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
78704 BIRC
Date. y '-?. 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:
( )
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.
�(bi) I have and will maintain workers' compensation insurance, as required by
Sebtibn 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 3FATE MID Policy No. 44.2093101,
(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"
yagree that if I should become
subject to the workers' compensation provisions o�Section 3700 of the Labor
Code, I shall forthwith comply with those.;p`owslons.
Date: e'- 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.
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
f�inspectlon purposes.
Signature (Owner/Anent)='`r% Date
PERMIT #
-BUILDING PERMIT
DATE VALUATION yy�' A ppy LOT TRACT
nW 8. w✓�ltH )�Ki6�f7 /n]'aPs.bEa .
JOB SITE
.ADDRESS.
APN
OWNER
CONTRACTOR / DESIGNER / EN INEER
SANDY ARFU
45-05DROOK:1ANE,
72516FJEAVER(°,AIr.�M' M- .�'
1.mpINTA CA a'2 S3
PALM t -V, IR.T C.UA: 92260
USE OF PERMIT
PF100 R
6043.P. PATIO C(WER, FXP CITY STAND.6!}UD
PORCPHIPAT10 60003F
XNITA;t4Es,P,'w5+' h ORI' 0,T11 COOMMA7C1.7.iFON
�Y,411��i.A'•.4?
PIAN C1l= ng 770.20
C04STRUCTIO'M FEW 101 -w0 -t 18-0iyi $10.44
STRONG ONO hi0T110V.*.nE - U'.l31.0 101-000-241-006 C80
f
I
F�QUIrT,4NCE®Ep7
L
CONM-1 EIC';I10ii AWI)* P3.04 CHECK.
�W.W-:I'DI'AL
TOTAL ";R,?4Tr11r1!XS.U(TE 14OW
$1.79.00
RECEIPT
DATE {
BY
D{P(/ATE N LESPECTOR
IN
r /
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings �j -
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. l
Fans & Controls
_
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall -Int. Lath
Final
Final
BLOCKWALL. APPROVALS
steel
POOLS - SPAS
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
Pictures
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
P.O. Box 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
May 14, 2002
i
(760) 777-7000
FAX (760) 777-7101
r ;o ;?NTA
1WAY 14 RECD
Paul Quinlisk
2544 Suite C
White Water Club Drive
Palm Springs, Ca 92262
Dear: Paul Quinlisk
Your check #6028 for $ 50.00 has been returned to the City of La Quinta marked "I
Funds" by our bank. In addition to the check .amount, a charge has been applied forna total ient
Payment for a total due of $ 80.00, in the form of Cash, Cashier's Check or Money Order. As a
courtesy, the $ 80.00 is due on or before May 28, 2002. If a
yment is 'not
this matter will be turned over the Riverside County District Officeceived by this date,
If you have any questions please,call Missy Mendoza or myself.
Thank you.
Sincerely,
John Falconer
Finance Director
cc: Tom Hartung, Building & Safety Director
ELl
Business License No.:V
BUSINESS LICENSE APPLICATION FORM
APPROVED BV DATE Y % D
' - ***+I*******ew*tee*****,►*e*+r +I•**w*
PROOF OF WORKER'S COMPENSATION INSURANCE IS REQUIRED PRIOR TO icelle�.�e
1. .Business Name: /Ci �� ar,r ra L..+
2. Business Address: 2;13. Mailing Mailing Address: F
4. Business Phone:�-
5. Owned By:' CORPORATION PARTNERSHIP INDIVIDUAL
6. If Corporation or Partnership, Tax I.D. #:
7. If Individual Owner, Social Security #:,--S- (0 3 7 7f O
8. Name of Owner or Officers and Title: _�i Ll+&..•l
9. SBE Resale Number': ?
10. Number of Decals Needed: 3 `
Vehicle License Number Permit Number (Finance Dept. ly)
�.►OF .cam
11. CONTRACTORS ONLY: Coov_of State Contractors License Pocket CardIs guired
7.
A. Type of Contractor:. '
• B. Classification � //0, 4,1,- i&Z&lJ.,OpryT
C. State License Number: 2q7v?
A or B License Classification $100.00 Per Year or $50.00 Semi -Annual
C License Classification $ 50.00 Per Year or . $25.00 Semi -Annual
I HEREBY CERTIFY that all the information supplied by me is correct and any licenses required by the
County, State or Federal Government have been issued to me and are in full force and effect.
-30.'-0
Signature Title
Date
Send Completed Form To:
CITY OF'LA QUINTA
BUSINESS LICENSE'DIVISION
P.O. BOX 1504
La Quinta, CA 92253
r