0308-237 (SFD)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
728102 B Hic
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:
( ) 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 withr 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:
O 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. My workers' compensation insurance carrier & policy no. are:
Carrier . QU)RE1'I1L4I.IC INSU Policy No. MWC`.iOD84 400
(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 of Section 3700 of the Labor
Code, I shall forthwith comply with,those/provisions.
Date: 1421 ) IA3 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 for inspection purposes.
..-Signature (Owner/Agent),Zxz'"/,/✓/ 'Z Date AP?V3
BUILDING• PERMIT PERMITk
DATE VALUATION LOT 03M.-237 TRACT
305211.1
JOB SITE
ADDRESS 44.8=5 IFUs. ALOND.UkAEDf
APN
E-�%�a-wtl�
OWNER
CONTRACTOR / DESIGNER / ENGINEER
,i..Z�, WAR HtOIU OF CWLIF MZ44
LW-4119AR KOMI OF CE L31FOR 'iA ,
78.401. C 1-1101iWAY 111
7t8.401 CM011WAY I l i
L.+o. C UD.\ "f A CA 92253
I.It, QU.i ITA CA 92253
( GO '%'11 -ilial Com.+# 3434
USE OF PERMIT
511`10.111OT 33, P.LAIJ ryies wca fl!?C1vuDet3i,f~2m
WALLS, POOLS SPA. 01i-'0R,1Vt--,WP.Y,Af PRIG )ACtl
'ild.t4CT i,C3WnRUCTION �gxoo s
)pO§irCHI.pATIO . 359,00 Sy
0.%RA.41,1CAR POR,T 40,00 8F
ES"1THMED ('09f OF ClaWB'A;IMC` 01N
169 17.41,60
CONSTRUCTION FEE, lilt-000.4'18•x000-S�F9.30
'K.Km CHECKilllt Ydi-0i2tl-flip-�1�a �i�y.?fl
MECHA.l ilCAI, FER 101-000-421X000 $600
91-,PCTR1CA.L tFZL? 101A -000-420-000 $14339
PLUMBING ►SER 103.000.419.000 5179.23
STRIG)' O MOTION FSS • M:5ID 101 -000-U 1-000
0- W, 1340 FRE. 101.-000-423-000 915100
DF,V ,L0PP4R IMPACT I+T'E $44n00.
RUR -IMA L CO iRDC13:09:it]yDPI44AW• C��3'q{.>r,//CK
T4A4tt4yy.:3y30
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DEC 15 2003
R CEIPT T' fifi��.
BY i
DATE IN D NSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms Footings _ _
Slab Grade
Ducts
Return Air
ff-
Steel
Combustion Air
Roof Deck .
O.K. to Wrap — —
Framing _
Insulation u0-
Exhaust Fans
F.A.U.
Compressor
= Vents
_
/ `
_ �f
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
_
Party Wall Insulation
Condensate Lines
/
Party Wall Firewall
`
Exterior Lath
i
Drywall - Int. Lath �('
t
Final
�
Y
_10
Final
POOLS -SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APP ROV S
Gas Test
Electric Final
Waste Lines
Heater Final
Plumbing Final
Water Piping
_
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
COMMENTS:
-
Final i
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage WiringIL
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) �' =