0308-241 (SFD)LICENSED CONTRACTOR DECLARATION
U) I hereby affirm under penalty of perjury that I am licensed under provisions of
F.- Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
04 W Professionals Code, and my License is in full force and effect.
p =) ch License # Lic. Class Exp. Date
wLO
X r-728102 13 T9IC 913004
oZO r Date � '�� �% Signature of Contractor
J U OWNER -BUILDER DECLARATION
HOw.. I hereby affirm under penalty of perjury that I am exempt from the Contractor's,
U) License Law for the following reason:
Z_ ( ) 1, 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).
cr) () I am exempt under Section B&P.C. for this reason
LO
N Date Signature of Owner
OC
CL Q WORKER'S COMPENSATION DECLARATION
It � I hereby affirm under penalty of perjury one of the following declarations:
Lo H O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W y: compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
m Q C) ( \)` k`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
fl rn H permit'.is, issued. My, workers' compensation insurance carrier & policy no. are:
ob z Carrier'ob Mi. OLD impunic nau Policy No. MWC100045 00
� O
J
(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
1 subject to the workers' compensation provisions of Section 3700 of the Labor
••v7 Code, I shall forthwith comply with th6se provisi,9ns
i ,Date: / �'.i� •f/J Applicant �,��,/L'�/�lens
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, interes�t 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
Y the above-mentioned property dor inspection purposes.
,iSi6nature (Owner/Agent) ¢ / 'f ry Date P %7r 43
• BUILDING PERMIT PERMITk
DATE VALUATION LOT 03M24I TRACT
7 SCSI -1
JOB SITE
ADDRESS 44-900 VIA ALC3.d! A) t-
APN
OWNER
CONTRACTOR / DESIGNER / ENGINEER
INO AR BOWS OV CAbLJ.FCi1dJ °�
Lr.3W, R 1.10 oa ''s OF C°AIi'olt'.AI'1A
78.401 C 01TWAY 111
78.401 C HIGHWAY I I I
%,AQUIUTA CA 92253
LAQEMr A, CA 92253
('76,CVy777.013I CHL4 3414
USE OF PERMIT
SINGLE FANNY DWEUING
SFT) - LST 9, FLAW 7& PG_RM..1T DOFZ, NOT INCI.I DF, 81.,OCX WALLS,
TRACT CONSTRUCT 10-N 4593.00 By
PORCH/PATIO 358.00 We
CIAR./113110MPORT 462.00 Sig
ESTI UD Ccagt OF CON1;n *rJC:rWK
1541MA0
Y
PFRAUM STATUARY
OONMIXTION FEE 101.000.4.10-003 $832.00
PLA24 CtiF:C:K:ME 101-000-439-318 $605.09
MECI3ANICAL.. FEE 101-000.421-000 $60.00
&L ECTRLCAL, ME 101-000-420-000 $133.517
PLUIv B NG T,U? 11 101 -000 -419 -OW 516712$
STRONG 2JiOTION F&S - MIND 101-000-241-000 $13.47
GRADING FEP, $1:5.00
D1 FiELOPPIR,iMPAC T 4U s -p- 3.00
1300-TC)7(.AL COX�,'!"RITCTION AND 2` LAW CiECY,
$4,313.38
LROVS PREIPAID Wo
$0,00
6
$4,313.:5
U A1, �C'IR.�+AAUT K% IlIT 9 NOW
DEC 15 2003
CITY OF LA QUJN TA V
RECEIPT___
RE
�
BY �
D MALE SP CTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS.
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
_ _
I_
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
O.K. to Wrap
Framing
xQ _ _
-p
Exhaust Fans
F.A.U.
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
ju
Final
Final
2
POOLS -SPAS
BLOCKWALL
APPRO ALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVA" .
Gas Test
Electric Final
Waste Lines
Water Piping
i e
�-
Heater Final
Plumbing Final
Equipment Enclosure
_
Plumbing Top Out
Shower Pans
O.K. 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 x
la
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)