0307-306 (SFD)LICENSED CONTRACTOR DECLARATION
U) I hereby affirm under penalty of perjury that I am licensed under provisions of
H 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 Cy LO f�7l
M License
clLic. Class Exp. Date
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UJ
oZ r Date 7� o� Signature of Contractor
co0�
J U CID
C) OWNER -BUILDER DECLARATION
W LU 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).
co () I am exempt under Section B&P.C. for this reason
Ln
N Date Signature of Owner
Orn
Q WORKER'S COMPENSATION DECLARATION
o Cr I hereby affirm under penalty of perjury one of the following declarations:
Lo H 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
mJ Q performance of the work for which this permit is issued.
Q U 0�)" 1 have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
rn H permit is issued. My workers' compensation insurance carrier & policy no. are:,
NT Z Carrier i,;�sJ {�')'�t :i� !'T},tA.l., Policy No.
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J (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
Code, I shall forthwith comply with hose Visions:
,Date: 2 Applicant'
"•: 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
4 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 inspec on purposes.
f ` Signature (Owner/Agent)%;//•`c!'�i " Date
BUILDING PERMIT PERMI VIY"#
DATE e VALUATION 1331 1XV) LOT TRACT ,: ~
JOB SITE 4W=514 3 "D )D17. Mr
APN % a _1.N9_0? f
ADDRESS
OWNER
CONTRACTOR / DESIGNER / EN 1NEER
-i2; 111TJK 91100
:A- 17,?1,7LID W!'1V0 0)0;0
X73 7}'••W.4;_R1}1F1G
D-J�ititV 7l %*' d' CA 9z260
.160
-AAM lFaAT CA �M
USE OFF PERMIT
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W'A i,,I„1, P10f' A ISPA OR, ljRIV ;t AI' APPROA.04.15% KE !kiC"k K)w TO PIAN
i,:H?,CK 14?*f? biUr!, TO :taiJIoTh3'.0 F, !Sutr.ANCP• OF SAME P LA.14 TYPE
01fY O"M CaNSTRUC'3'IL N 'N941,,0 BY
h S;I1t11PATI0 501L oil' SF
eAPrs 0h7CAHVORT M00 Sig
� Ots 'l'S�U�'riC3?? 101 -MG -4- 1RI'•-00) gi,4J6,50
PLAi,I CHECK Fli'. 101-1:1>at%439-318 W7.31
W'f1..ANICAIi M,10�:�{it30•�2�.-qUc� $150.0
E11=1RICIA.1 FV 101-000-420-000 $30.69
P"WM8190 ATZ 10 1. _000-4 19-000 COCA,
."'RONC, MOT1011Z PEE o kirSID 101-000441-000 $32.19
0I1DdI?"IfF?T 101-0 0--!3"000 $150
D..V 21.4 PP,...K I.M',MCT 1,1 4 �,ii!l5,t11�
.ti�R M PI,1;s1, C M - i#t.; ! ."e."I0.0004 E.5-.0 0 SX4. t4 '
uMs.,WfAi., C0X91*;RTJCfr10!T M f.LIQ CMECK
AUG 20 2003
CITY OF LA QUINTA
�
FI9�ANCE DEPT.
RECEIPT
DATE 2
BY tt
N
1 SPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 8 Footings 171
Ducts
Slab Grade
Return Air 10
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
A.U.
Framing _
Insulation
Fireplace P.L.
_
Compressor
Vents A j
Grills
Fireplace T.O.
Fans & Controls -
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. 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 Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines d
Heater Final
Water Piping c.2• ✓'Q
Plumbing Top Out
Plumbing Final
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 APPROVAL
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service .
Sub Panels _
Exterior Receptacles
G.F.I.
Smoke Detectors IL J
Temp. Use of Power
J
Final AJJI 4Z
Utility Notice (Perm)
COMMENTS:
J