0308-031 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
I-_ esChapter 9 (commencing with Section 7000) of Division 3 of the Business and
cel W Professionals Code, and my License is in full force and effect.
-0 ch License # Lic. Class Exp. Date
640934 i� f�1 03rd 117K
t �a L .+�1- (r
o ZO r-,Datee Signature of Contractor C A__
J U C:) OWNER -BUILDER DECLARATION
W WW r- I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) 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).
( ) I am exempt under Section , B&P.C. for this reason
LID
N Date Signature of Owner
ON
O)
d Q WORKER'S COMPENSATION DECLARATION
C) Z I hereby affirm under penalty of perjury one of the following declarations:
Lo F2 O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W LL 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.
m Q C) ( ) I have and will maintain workers' compensation insurance, as required by
O LO Q Section 3700 of the Labor Code, for the performance of the work for which this
Il 0 Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier WAT..1074A1,1JAiION _V Policy No.
obs
�p
Q (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
3 subject to the workers' compensation provisions of Section 3700 of the Labor
Code ,eI,shall forthwith comply with thoseprovisions.
Date:' � I -:Applicant Q -1 t .( AI'.-
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
1 of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
14
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 I
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 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 authorize representatives of this City to enter upon
the above-mentioned propertylor inspection purposes.
-' °/tip..
� ignature (Owner/Agent)T , � �S •�-"'' Date`
7 BUILDING PERMIT PERMIT#
0308-031
DATE VALUATION LOT TRACT
13 30023
JOB SITE
ADDRESS 814nn 5 DANIEL DRIVY
APN
764-270-017
OWNER
CONTRACTOR / DESIGNER lEN INEER
SIMA HOWS
SMA ROM"
81.2Ci0 A'J'ENUE 612
81.260A' EIM 62
1A QUTNTA CA 92883
U. Qi]IWA CIA 9288
(909)833-;3996 CSS 68r'16
USE OF PERMIT
RFD
SKD - LO i° 1% PLAN 6430C.. PE"IT DOES NOT INCLUDE BIDCK
WALL2, P004 SPA OR DCiti,+ �V�'.� Y APPROACH
C�CI1ST,Otl'dppi C,rOpNSTRUCTIO14 %769,00 SFF
rO�F.WI PA! -IO 214.00 S
GARAGWARPORT 719,00 SF
],rY1,MA:rKff2 con OF Q:omuclION
232;c .+"x.70
1' d Vild YEF &tI1i A,1 Y
CONMUCTION FEE 101-0001418.000 31,195,00
PS Aft CHECK FU
MECHANICAL FE& ` ' 101-000.421000 iB1.�0
ELICTPUC.RF. PEP, 101-100-42£1-000 $144.80
PLUMBTf!6C1 FEE $166.00
STRO.N€i fAOTION FRE, RESID 101-000-241-000 $23.26
CII AD410 F?9 101.000.4123.000- $15.00
d3EVEL-OPER IMPALCT FEE �2;3�►9.80
ART 114 PUBLIC PLACE RESIL ..270.000-913-000 $31.61
SUB-TUYAL CO}MIMCM09 AND PLAN C aWICK
°$4,9103.32
1. FM PRE -PAID FEM
$0.00
n IrOTAL PE'YiW>!':1'M-8 DUE NOW
$4,91032
SEP 12 2003
w ,
NTA
ECEIPT FINANCE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
I INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel J
Combustion Air
Roof Deck 0
Exhaust Fans
O.K to Wrap . 9-C
F.A.U.
Framing
Compressor
Insulation -
Vents
Fireplace P.L. V I
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wail Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVA S
steel
POOLS -SPAS
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 T.op Out
Equipment Enclosure
Shower Pans
OX for Finish Piaster
Sewer Lateral.
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test ,.:.
Appliances.
Final
Final
Utility Notice (Gas) 'For
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:
/