0308-244 (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 A 9/30/04
'Rate Signature ,l3 Signature of Contractor
OWNER -BUILDER DECLARATION
LU I hereby affirm under penalty of perjury that I am exempt from the Contractor's
N License Law for the following reason:
Z_ ( ) 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). • ' •
N( ) I am exempt under Section B&P.C. for this reason
N Date Signature of Owner
Q WORKER'S COMPENSATION DECLARATION
Z.
I hereby affirm under penalty of perjury one -of the following declarations:
Q 0 () 1 have and will maintain a certificate of consent to self-insure,for workers'
Ll compensation, as'provided for, by" Section 3700 of the Labor Code, for the
J Q
performance of the work for which'this permit is issued.
Q L) ( ) I have and will maintain workers' compensation insurance, -,as required by
J Section 3700 of the Labor Code, fqr the performance of. the work for which this
Zpermit is issued. My workers' compensation insurance carrier & policy no. are:
�o
Carrier OLD RLPIJPLIC rA81) Policy No.
� Ih WC100R45400
C3
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
subject to the workers' compensation provisions of Section 3700 of the Labor
3' Code, I shall forthwith comply with thio§e,provl ions -
Date' J .1 r j �,/I _' Applicant
r� 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 haverread 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
A the above-mentioned property for inspection purposes.
Y Signature (Owner/Agent) /��!� Date
BUILDING PERMIT PERMIT#
0108-244
DATE VALUATION LOT TRACT
JOB SITEM
ADDRESS 44-84,AL0PMA
01•IJP
APN
604r -02--M
OWNER
CONTRACTOR/DESIGNER/EN (NEER
I"2'3,Eti.T2 IT -016F-8 OF CALWORCtMTA.
7,�'N.k~lTAR HOME' 01- C.F 1X-- RN A
78.40) C 11f:C1'1WAY t i l
76.401 C 1110,11WNAY 111
.LA QMI'!.A CA 9.2253
LA Q111NTA CA 92253
(760)777.0131 CBL) 3434
USE OF PERMIT
3C�JY_ FA9 3f Y D M-- &0
SED e ,.W' T is Pia 1, XB. PEIRM)'P DOESNOT IRCI..UDE BLOCK
WALIA P00I4. SP.A, OR DRIVEWAY APPROACH
TI?ACT C0143TRUCTRON 2,tx1fi.00 SP
POR(rHIPATIO 488.00 SF
0AIdAOFIC.A 3,PORT ' 462,00 Sly
ESnW. _T SD C057 OF CONS".l . MON
150,897.60
CONSTRUCTION Pisle 101-000.4'16.000 $846.00
-
PLAN CHECK PFE 101-000-439-318 $175.7.3
MECIMWIC: A, FEE 101,000-421.000 $Y3.Q0
ELEC` RICAt IrSE. 101-000-420-000 S135.14
P(.UMBINO FIRE 101.10004.19 000 $194.00
r
STRO14 , MOTION 1 F, Ft1? 5113 101-000-241-000 $l5.Sa
CUDJNO FEE 1.01-000.423.000 516.00
I EVZI.,Oi'}?AJMPA.CT ITE, $2,405.00
r
ry
UM1014 AND PL" CM CIC.
$3,A49.76
^{� A JMV PItR-PAWIMUS
.$0,w
JL Z:+i4CYdSd rQW-'S DULE NOW
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CITY OF LA QUIN T6A
FINANCE DEPT- /
41 ✓
RECEIPT
DATE
BY
D E FINA
I PECT
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Slab Grade
Steel
Roof Deck
O.K. to Wrap
Framing
Insulation
Fireplace P.L.
d
{� _
_J �� _
.��_ � f
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
,J '
,
T
_
�
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Ones
_
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Ficial
_
Final /0
BLOCKWALL APPROVALS
Steel
POO6S : ms
Set BacksElectric
Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
i Gas Piping
PLUMBING APPROVALS
Waste Lines_ _ _
Water Piping - _
I Gas Test
Electric Final
Heater Final
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
14
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures 41,
Main Service
Sub Panels
_
Exterior Receptacles C
G.F.I.
_
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
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