0308-026 (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
X640934 B /•-, 03 1/2
Date`'+ t! ! !';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, Business & Professionals
Code).
() I am exempt under Section B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
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
Sec ion 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 NATIfd►'i 1.L L!g.10?3p., Policy No. 70851"9
(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
Codetil "shall forthwith comply with those provisions.
Date:" I I .. t ,; Applicant tZ S �_ G.
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 t
any permit issued as a result of this applicaton agrees to, & shall, indemni
& hold harmless the City of La Quinta, its officers, agents and employee
2. Any permit issued as a result of this application becomes null and void i
work is not commenced within 180 days from date of issuance of suc
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 i
correct. I agree to comply with all City' and State laws relating to the buildin
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned pproperty,for inspection purposes. t
Signature (Owner/A'gent) 3 AZI- �Y k A I,- Date
BUILDING'PERMIT PERMIT#
0308"•0m
DATE �Y
! / VALUATION LOT1 s TRACT 30023
1
JOB SITE
ADDRESS GJA IiDAMELU.
APN
764-27"17
OWNER
CONTRACTOR DESIGNER /EN (NEER
6rrwA rWZ
vr-,A 1.10
fat -260 AVENU1v RC2
81.260 AV:cNM 62
Lei► QUIMA CA 92883
LA QIM4 TA. C6+; 96883
(9b9}t3.33-8994 CST.# 6VI6
USE OF PERMIT
WD
SPD a LOT 19 PLAN 4a10C:, PERMIT 00FE, NIOT TNCLUOE BLWIC
WX&S, POOH SPA OR DRIVEWAY Al'i'kOA("ft
CUSTOM CONSTRUCTION I,610,DD SIS
PORCiiIPATIJ M00 SIS
0ARA:L`1Ef4°,AR,PORT 474.00 SF
ERIUM12D COW OF 0101 1711VYU0T1F X
1'4.191'T38,80
CONSTRUCTION PEE 101 �000a418n000 rr, 6.00
`
PLAN CHWK FSE 101-000.439.3181 $619.1m
.
MECHANIC',AL klE ' 101-006.421.000 $09.59
.
E1,.EC7 R3CA.L FEE 101-000-420-000.
PLUMBINO I4,.E 101=000-419-000 S1403S.
STRONQ MOTION! FEE -TI-if;SID 101-000-241-000
ORA,DINO FEE 101,1000.423-000 3I�.D0
DE ESL0PER:IMPACT.F'1�1r, ly�l+Ct3.(lU
U.,". 'I" COXI8TR1JC` MON AN G��CCi�
•,1X39.'23
e 1Y.5� PRF, -'AR) }� .9
'�' fAAiL�'�',ERWrMSSDU3_,�ow
$4,1fes, A
EP 12 2003
C.FINANCE
Y OF LA QUINTA
DEPT.
RECEIPT
DATE A
BYTE
QED
INSPECTOR
i
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
nderground Ducts
Forms & Footings
Slab Grade
Ducts
Return Air
Steel
Combustion Air
Roof Deck
17,
Exhaust Fans
O.K. to Wrap
J
F.A.U.
Framing
— -QCT)
Compressor
Insulation
,(j7
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
fA
Drywall - IM. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
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
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
tf
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: