0307-188 (BLCK)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
"x'36920 03/31/2(
Dae s Signature of Contractor
OWNER-BUILDERDE ARATION
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.
( ) 14•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. My workers' compensation insurance carrier & policy no. are:
Carrier STATE FUND Policy No. 13-764W2002
(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' compensationplgvisions'of Section 3700 of the Labor
Cade �l 1 II forthwith comply with t 6s rovisions.
Date:_— Applicant
Warning: Failure to secure WorkerrleJ�C�enalties
ompensation coverage is unlawful and
shall subject an employer to crimina 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 whosebehalfthis 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 'rosgection purposes.
Signature (Owner/Agent) Date
BUILDING PERMIT PERMIT#
DATE VALUATIONLOTTRACT
6 s2q 5DAI)
JOB SITEt3��
ADDRESS �5'-, 00 A'a. W)A �f y ADi.At�wS -0
APN
OWNER
OWNER
CONTRACTOR / DESIGNER / EN (NEER
BOB 1CMXV30
1^ obis
R0, BOAC 114)
5 13 7 0 ,@,VMi' A BEM— ODA0
I.A. QTTlNTA,. CA 723233
LA. QUIN to CA 92253
(760)568.14,04 CSUI 6255
USE OF PERMIT
GONFRAL DIF1'IaT.3i1IG
LSO LF Ct)MHO 2' 9,RTAtT4L1xC3 VnT'ti d' O0IDEN WALL '100 LF &
WALL-ORCO BTANDARD,
r .
6 lr7'. WALL 250.00 LF
C
Iiwla�t'It12am CQST 0M, c0 7M. ON
PEW(T b'ZrE 90111MARY
CONSTRUCTION FPX. .101 -000 -418. -GOO S90.4e1
JUL-1.5- 5 2003
CITY OF LA WNW—
FINANCE
"w
SM -TOTAL C0NMUCTl011 P14D PLAN MEC`IC:
$90.00
LESS PRE -PAM M PM
$0.00
'.( ML g';�.,I,t��'U VERS DUE NOW
S90>f)t1
REQUPT
DATE,l l
BY.
f)ATF FINAI:.F.O
INSPFCTf1R
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
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam L!i
Approval to Cover
Equipment Location
Underground Electric
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
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
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)