0302-061 (AR)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
700(M4 a"• 0313112i
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 structureis 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. fo his reas n
Date - Signature of Owner r 1' f, A
WORKER'S COMPENSATION D'E�LARATION
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.
( ) 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 StAT1w 1111 Policy No. qB-J3- 0 3
(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: - Applicant �"'` ! A
1.11
Warnings: Failure to secure Work skCompensation 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, indern
& hold harmless the City of La Quinta, its officers, agents and employ est.
2. Any permit issued as a result of this application becomes null and vo Alf
work is not commenced .within 180 days from date of issuance of Li
permit, or cessation of work for 180 days will subject permit to cancella
I certify that I have read this application and state that the above informati
correct. I agree to comply with all City, and State laws relating to the buil
construction, and hereby authorize representatives of this_ City to enter u
the above-mentioned property for inspection purposes.
f r.j .
Signature (Owner/Agent) • 1 .� Date
G ��. •. ter.., 7 f
BUILDING PERMIT PERMIT#
DATE VALUATION ,.} LOT-�� TRACT
JOB SITE
ADDRESS �•�{� }�
APN _
OWNER
CONTRACTOR / DESIGNER / EN &NEER
3.a<1M RAmIAMJ
FMffT PhWICA 37E11`,�L.fJPbfKW "CORK
'
.1 ED AMS Ch 92373
' •
(909)798-3688 C73 A 4911
USE OF PERMIT
.' = IUMML AD1�1 ICIN
ATTACHME11 CA, ITA(928 S.13.), 3'fr1 MIT INCLUDES 119 S.V. PATIO
AR A
CUSTOM CONSTRUCTION 3.23.00 9F
PO1ZMI PA'170 1 19.00 a^P'
QARAOL+6O'.AI PORT 31.00 OF
Eg�a�.3�i1'.4:'i.l✓�_1 COi1��' OF COi�NS�°.t�UQ`'.�ON
yf y ry+ �y9: :f Ct,{�
PURMI.i. JI7 A!aE �'�VD� A '
CpaBfl'F UC TION IME 101.000418.000 $271.50
)?S.&K CHFICK TEIXI 101-000-419-318 V .72
MECHANICAL M9 .101-000421-000. $45.00
LiJZ yR3U.L PRE- 101"/80-420-000 $.x°1.40
PTIUMB NO P99 101.000.419.000 $M- 100
S!'RONO MOTICi'1,1 lt`FX - REST 101-000-241.-000 Via.°as
ORADINO VU 101-000.4*t 0 �i13.00
8Til B AVTAL 00. . %XX- 0)4 AM PLAN AN OM
$0.00.
DUE NOW
MAY 21 2003
.CITY OF LA QUINTA
FINANCE DEPT. '•:
RECEIPT
DATE
BY
D A F ALE
IN SP T
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
1ADucts
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
A 10
Drywall - Int. Lath
V
Final •
Final Z/
BLOCKWAL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. 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
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
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)
COMMENTS: ,