0302-142 (BLCK)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Fes- Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
04 W Professionals Code, and my License is in full force and effect.
O 5 co License # Lic. Class Exp. Date
ti w 4516392 C%C29 08131P7el
oZ r- Date Signature of Contractor
co 0 r`
J U C:) OWNER -BUILDER DECLARATION
HUJ I hereby affirm under penalty of perjury that I am exempt from the Contractor's
Ila -
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).
() 1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code). ,
ce)() I amexempt under Section B&P,C.I.fcrr this reason r.
O N Date �� 6 i i Signature of Owner.. -
0 °)
Q_ Q WORKER'S COMPENSATION DECLARATION
O Q 1 hereby affirm under penalty of perjury one of the following declarations:
� 0 () 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 I have and will maintain workers' compensation insurance, as required by
QU Q Section 3700 of the Labor Code, for the performance of the work for which this
2U')
Z permit is issued. My workers' compensation insurance carrier •& policy no. are:
Carrier�1Qrstloa JAmw f� Policy No. Qlkratt.$'S'm
ao �
r` CY
g (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
3 Code, I shall forthwith comply with those provisions.
Date: ' t -A k N-% Applicant 1.`[ !'.A, *v -G 3 S4
Warning. Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines u� to $100,000, in
addition to the cost of compensation, damages as provided forf�n 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
�^Vip & 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.
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 property for inspection purposes. ,
�. • Signature (Owner/Agent) � } � Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT W02,442 TRACT
02/199(. S111W0.00 ? 5 y 30023
JOB SITE [Yw�7�. ♦�t APN
ADDRESS .�72 �i±'�.a1F,.RT.,;M1D:s�Vi{f )tv v
OWNER CONTRACTOR / DESIGNER / EN (NEER
01TEAROMRS PACWC IYLAXOx+"7z Y, Wit.
811-260AVENU.1 ~ 6Z 1 Ot;a W. CIVRCAIR AVY1.1 SUITE J
CAS 92863 011A1vGE CA 92805
(714)282-0212 M4, 06272
USE OF PERMIT
4401.` 8' E0,(X`1C''WAI4L PER C'RCO S'"ANDARD &C:DD F,1'PR;O''V.E0 PANS
6 FLIVYAL1, 4400 LF
WSUMATED MST OF CQMT.CRUCTION IM "10)
CONSTRUCTION RE; 101-0001-41U-000 $126.00
KTB-TOTA% CONWRTM310 i' AM PLAN CIMC C.- $126.00
IMS RRCE-PAM, FM?3 $0X10
TMAL i'FS2VYd'MRS I AM" HOW 41.20.9
SEB 19 2003
CITY OF LA (�UliNTT
CPT A
RECEIPT ��.= BY DATE F AL IN E R
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
Steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
_
Main Drain
Bond Beam
//Approval
to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
// a
Gas Piping
PLUMBING APPROV S
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: