0308-016 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Imo- Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
N W Professionals Code, and my License is in full force and effect.
O M License # Lic. Class fExp. Date
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t►R ii34 -'3 Frt» !- X 3113 1 XGA?
oZ Date §�r t� Signature of Contractor'�•'f
(o O
J U � OWNER -BUILDER DECLARATION
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ .a 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).
ce) () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
ON
0)
d< WORKER'S COMPENSATION DECLARATION
C) Z I hereby affirm under penalty of perjury one of the following declarations:
U-) O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W 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.
CD Q (� ((:). I have and will maintain workers' compensation insurance, as required by
O (-) Q Section 3700 of the Labor Code, for the. performance of the work for which this
CL rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
1�t z Carrier 3•d1'T3,:)r$/ f'UNS«32i A�: Policy No. M.4109
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(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 t9.become subject to the
workers' compensation laws of California, and agree�lhat if I should become
subject to the workers' compensationprovisions of Section 3700 of the Labor
Codec I hall'forthwith comply wih those prolyisions.y'"""^�.
It•_ t LOApplicant
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 daeys from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
r
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 aut6iz8 representatives of this City to enter upon
the above-mentioned pro4rty1for in'spect'ion py`rposes.
'Signature (Owner/A4ent)°°-..1 j- �"'rte Date
BUILDING PERMIT PERMIT
(MA -016
DATE VALUATION 4,1 117,691.10 LOT 73 TRACT 30023
JOB ADDRESS ! i a 41116j, DANM'U, DMEVE
APN 764-21 70-0 •i
OWNER
CONTRACTOR / DESIGNER / ENGINEER
53.260 AA E, 62
31 ,WO AVE. WE R
C1A �4 a
LA Qt7 RrA �A.
(909: )833.6996
USE OFP
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WALLA '004'5kPA OR 1atINTWAY tPP?2f.IACH
Pf�:CrFii'id 234.90 VY
41KOD 3F
00ST OF C0,111TVIV13f.:" ON
13, ;1ufi: 1. f£5
•�. 7�p-�C� y q�L }�y��''p $ g3}�.�Yy:?XM;.ti.:!';�19
.T ��rl LYllb i[[yy�.3i .67A(��l{�11�.1trA0..4-1�.
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t..�.Jl�iw9 F1.I�.S+0ul.ION FEE }t,�) C00 -Ah" 15-01O ,A 7L'O�*
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P1..4 ,1 (11l'i K rz9 1 •i -030-439-318 $572.83
PLUMB NNG FRE 'i 1%1 .r,iw, r4 1 5 __000 81 KIM
S TRO�NO 140TI(: N 1rEY < }i' -1" 1.Dx;1.77
1") FV Z1, 01.1 EIR JIM P.A..CT )YlSf?;
;��-TC.f"I',�:L t'"t:?Y•i�s`�; ..�;:,y�°i�:?.;�` ��7£' i'I.�.l�3' �'n•�s�-:�
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1 yj'�+j y�1 DUE
1101S'A."�.i 17XIII, J: XI ) .1J�'L�E �lgcftT
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p471�i�a� r
SEP 12 2003
CITY OF LA QUINTA
FINANCE DEPT.. I .
j"
RECEIPT
DATE
BY
.i-
DOTE FIN AyED
INS OR
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 VUlm VLiCompressor
Insulation Vents
Fireplace P.L. Grills
Fireplace T.O. Fans & Controls
Party Wall Insulation Condensate Lines
Party Wail Firewall
Exterior Lath 1 :11.412
Drywall - Int. Lath
Final
Final POOLS - SPAS
BLOCKWALL APPROV LS 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
COMMENTS:
Final 17
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)