0307-304 (SFD)61
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
'77 7 699 4430;'04
Date � �"� �' � Signature of Contracto&v l, ��•O�•''""""
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_ c3s`provided for by Section.3700 of the Labor Code, for the
performance of't#ie 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 LIBE z;T Y 11.0V;} f ti,sVJr.' Policy No. �b°1� Gfa l?3;t3<i 1. V ., R �
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) I 'certity 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
Code, I
" s all fgrthwith comply wlt�hos
'e:l/_5 "Dat�r. �bio
c•-ems.-~"'�"'"
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.
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) � /�:'`: F �g�+� +''"""� Date
BUILDING PERMIT : PERM',- .�.�Yz
DATE VALUATION LOT iJ TRACT ry`ay{.f
JOB SITE
ADDRESS Sk-4= FL DORADO ]DRIVE
APN
OWNER
CONTRACTOR/DESIGNER/EN (NEER
1101,1-. $3 UZEIMS P40C
HROT-FIRMS S AIT
73.1 a] 1T'R?' �' DIGG HT :�.
33-411 �Fi"�L�i3'►' C�`�ititY 1.
(160)674-9699 C )14 ;3w:4
'
USE OF PERMIT
,. d�._t .i.A. O 1 sib NA 011 1�:\�2arG �L�s•�l�i �Slafiis7. n i,s �:�++n. i i.�:ic7;.w ;^fua ,
I0CUMV BLOCK WALL% FOOL qPP,, 02f, lak1,VEWAY ARPRO,4.aE: 75%
FX!7.3UC;TV3''N'. O Pt>.A24 CHWK PE :i_diX:'TO '91T'lbLTIPIX ISSUANCE. OF
C'U.TTOM S:�J1�1rFTF�tdt;7JE) 4 : 14F<i241 �'
T,sS"'iWf1719Y) t^€�.'�T (IF (Aa.�bil�iI'I. ULT1'ON
w C3x�S'PR °7301 i i'?sr� til = ",fR�(. E EtNOi F s!,3 uc
PLAN C1Vr.CKFF1CJ
VII. 2t1,AkII(1AL FEii •000
ZLECTRICA L IP:If, _0%).142.011000 Tf9i 0�
9r3� bSglF�tiaO s%C . lit'9.-000.419-NO 010.00
0140MOT)ONR.'.IND �p-i)17(1-2 1-UG(3 dna. 3J
WADING FRY.
OFIV'f i.SiRE 11MPAC?h. FEP
lwl M ,P13131AIC Pf1,!!W - P.%.�"3IIi
i p-' �'etiS.. C:C7�36'�7�2:�;� n,102'X .f'm.`s''���..I+x cnx'.",C.:°,F.'�
06, 06--
D �� ULn2hicf<1i4xxs:Dimnow
$4,514ti,�
EAUG 0 203
CITY OF LA OUINTA .
FINANCE DEPT
RECEIPT
DATE
-•�?•.
yl�c
BY
v�;-
DA 'FILE ..
CTOR
-
INSPECTION RECORD
OPERATION DATE INSPECTOR
BUILDING APPROVALS
Set Backs
Forms & Footings r
Slab Grade I v< <
Steel
Roof Deck r
O.K. to Wrap
Framing
Insulation i
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
>1 W6p-
Final
OPERATION DATE INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans & Controls
Condensate Lines
,X POOLS -SPAS
BLOCKWALL APPROVALS 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 . p Encapsulation
Gas Piping
Gas Test ✓
Appliances
Final
COMMENTS:
Final '
Utility Notice (Gas)
ELECTRICAL APP VAeS =
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G. F.I. IV
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
-1"