0308-242 (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
B Eric 1, 9M/04
Date Signature of Contractors%�f✓�L'��
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).., a
(,) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business A ,Professionals
Code).
() I am,exempt under Section B&P.C. for this reason
Date Signature of Owner
. 1
WORKER'S COMPENSATION DECLARATION
I hereby affirm -under penalty of perjury one of the following declarations:
( ),I have and will mairifain 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_ . ;
(/,y) .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 OLD REPUBLIC INSO Policy .No. #'C100345400
(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 thoseJprov signs!
mate: /,0 /,r ri'�' Applicant k/,✓%✓'�JJ d% ,
Warning: Failure. -to secure Workers' Compensation coverage is unlawful and
"§hall,s'46 t 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 rthe 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.
r -
„,Signature (Owner/Agent)-,'4!Date
BUILDING PERMIT PERMIT#
DATE p VALUATION LOT TRACT
I'llc
•p�q 6 10 3(11,§2 1 21
JOB SITE ]APN
.ADDRESS 44 -NO WA ALOMYR
OWNER
CONTRACTOR / DESIGNER / ENGINEER =.r
1✓ WAR HOMES OF CALWORMA
19bW.A1.2 HOMES OF C.:AL'R KIM.. Lk
78,401 C 141GAWAY 111
78401 C MGT. -T AY,111
'LAQLINTA CA 92253
u,Q1 °a & Cid, • 92253 •
("JR)Cij777-0161 CHU :431,
/
d-
USE OF PERMIT
S1W0LE J?%MLL1Y 1D'VtT.0 JN0 t
Sin'- LOV I0, .PL.AX 3C.R. PERMIT DOn NOT I-NC:L,UI)X? 8LOC K
Wtf.A:LIA P004 SPA OR CIR.IVru;WAY .&PPROACH
TRACT CONSTRUCTION 2633.00 OF
_
PORC:H/PA'P10 SF _
CAR.G'ACIL�MARPORT 1476,00 SF
µ
MWAT COur OF, LCNN CUCON-
1571175.30
PLlVUrQpp1qYMR
CONSTRUCTION FEE 101-000-418-000
PLAN CHECK F'.L;I . 01-000-439-3.18 �5�3. ►d
AA,L►CH&LAICAL FEE 101.000.421.000 WIWI
ELECTRICAL 1WE .l 101-000-420-000 $13. 13
Is'Lx.Im,i3li a" Fikk? : '.r.` - 101.OW47 9-000 X163.1
STRMTO 1diOTION FEE - RN. 10 101.000-241-000 $15.72
GR€lDMIGI• E 10.1.000.423.000 Isf5.40,
DEVELOPER IMPAC': FEE $3,105.GZ
r ti
SUB-`� i .G't71 "tJ�.'i]C�~t]L� 'AAID"!'Tad , t '1 C'iC
$4,334.58
' LH PRE-PAID,FiM
$0.00
trolln " "fes 1':EWW'IMSDITY.I'I'g1Ar15 2003
CITY OF LA Q1IiiNTA
FINANCE DEPT
RECEIPT
DATE
y
BY
n
D FI E Yr
I PECTOR
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 Wali Insulation
Condensate Lines
Party Wali Firewall
Exterior Lath
Drywall - Int. Lath J
_
Final
'final
POOLS -SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Waste Lines�j.rV
Electric Final
Heater Final
Water Piping o�
Plumbing Final
_
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX for Finish Plaster
Sewer Lateral
Sewer Connection
Pool Cover
Encapsulation
Gas Piping
_
Gas Test
Appliances
Final
COMMENTS:
Final r,
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
_
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detector's
Temp. Use of Power
Final
Of
Utility Notice (Perm) ✓�