0307-316 (RPL)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
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 with licensed
contractors to construct the project (Sec. 7044, Busines .&' Professionals
Code). i ��� •'
( ),.I am exempt under Section ,B&P.C.jforithis reason
Signature of Owner '
r
WORKER'S COMPENSATIONjDECLARATION
if
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 Policy No.
(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 gree that if I should become
subject to the workers' compensation provlsior�ss f"Section 3700 of the Labor
al VIS
Code, I shall forthwith comply with those,p(ovlslon
Dale:
Applicantf
i,�':�„ , A
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.4-ti''
I certify that I. have read this application and state that the above information isJ
correct. I agree to comply with all C_ ity, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for I.nspectii6purposes. / !
Ir,,Sighature (Owner/Agent) ' `” Date ti
e 4.
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PERMIT #
BUILDING PERMIT � �
03014416
DATE VALUATION X�y y�LOT TRACT
JOB SITE
ADDRESS 6 0 - CO TJ;) MI V) K R. L A HE
APN
OWNER
CONTRACTOR /DESIGNER / EN INFER
f,%t 'AR1.�y�1.�y99.�f .•i�('' s(:�ri�".�`,A�;�T.;sF. ,
�s tA�'i? ER " BUILDER:
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USE OF PERMIT
SKIM, =71F` ri.;.;>.. t!E AT L 1Klr! Wfe,.i/�t:
D3rf�)?�,C3'�ON. �t;?i,fl`f�TtSf+'!•1'1',��.:I,ObiI#ti�Ajtil 1TdC3..ij%�`I?
POLI ANIVOR SPA L -:t,
FLAP f—IJ MMI.K'FM 1tJ3.:f�t3��i��',:�cl� • �14d.25
0UN'S TRUCTIGNP& 1.01-M-4.18.000 �xa:S:t�Vv
NIAWRANICA.i M- y P06:C, 1:41-630.423OW
ftl�"�'�'Iz.Fsr,;g1. �: •> ��i�.i, i O i-t3fIU� �.(�• nGt� �?;S:�tl
mummimh"p•1�.- -pool, 1.01-000-419-000 $27,00
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JUL 2 5' 2003
CITY OF LA QUINTA
FINANCE DEPT.
QM..TO'i'AL CONVJRC,fC !`DOIT AND, T LIA14 CIMIX,
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RECEIPT
DATE �.
BY
F A ED
TOR
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 Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
.BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs1
Electric Bond 71
Footings
Main Drain
Bond Beam
Approval to Cover
- _ - -
Equipment Location
Underground Electric
Underground Pibg. 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:
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LOT 1®5
JUNIPER LANE
LA QUINTA, CA
60607 Juniper Lane Gi
La Quinta, CA 92253 CITY'0F;-- -A QVINTA SUB -CONTRACTOR LIST e * ? Wilmar Partnership
JOB ADDRESS PERMIT NUMBER OWNER Wilmar Partnership BUILDER
This form shall be posted an the io—b-with the BuMin g Inspectiow Card at all times in a conspicuous place. Only persons appearing on this list or their employees are authorized to work
on this job. Any changes to this list must be approved by the Building Division prior to commencement of work. Failure to comply will result in a stoppage of work and/or the voidance
of building permit. For each applicable trade, all information requested, below must be completed
by applicant. "On File' is not an acceptable response.
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...... ...... ...
Company Name Classification
License Number
Exp. Date
Carrier Name
Policy Number
Exp. Date
License Number Exp. Date
... . .. .. ...... . .
fe.q. A, B, C-8)
A Flores Excavating C12 'A
1xxxxxx)
610605
N�dxxlxxl
5/31/04
(e.g. State Rind, CalComp)
State Fund
(Format Varies)
(XXlWXX)
01/01/04
lXXXX} 1XX/XX/XX)
15009/004973/21/04
oil
-0
046 009513
J&L Material D06
;472187'
04/30/ Ol
te Fund
State
532 -0000137
01/01/03
0079115850
6/8/04
OL
�'603550`
01/31/04
State Fund
229-0024477
04/01/04
06717/
01/31/04
Mk:
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Herny's Steel A
Gattuso Pool Corp C53
I ..4"WW
672850.,.
06/30/05
State Fund
1615074
01/01/04
00816/14860
01/12/04
jA
Wesffall Plastering C54
664483
09/30/03
State Fund
046 -0007859
03 J3
CU
iiMALL
M
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Gattu so Pool Corp
-2860
06/30/05
State Fund
1615074
01/01/04100816/14860
01/12/04 d�
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