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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
7776W b 4330103
'G� s
Date �10244'; 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:
( ) 1, 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 own%r 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.
`(f ) 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 LADERT Y Nfl.i'I'UAL K Policy No. )gAp2'ljM1`i}` k-f0I2"TI
(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 those provisions.
Date: Applicant,4 b' ./ �''�••�
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, h,is
application. <
1. Each person upon whose behalf this application is made & each personat
whose request and for whose benefit work is performed under or pursuanfho
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)e#1_� � Date '?-//4A» a
BUILDING PERMIT PERMIT#
DATE VALUATION—
&W$89�0 LOT — 1.54 TRA
ADDRESS � «J }t s a �54 Y ✓R D' Al,7� Y D du JOB SITE
APN 7.2 -'2•:�'M i
OWNER
CONTRACTOR / DESIGNER / EN &NEER
mu, lalz }T km ft4C
'rOU, BROT14ERS4 RX
73.11.1 taxi
app �_ •' t� > r ,� �c tri
(760)674.-9699 CMU 3832
USE OF PERMIT
5Til� • f,��' ftdf,'31 x:A37'.�.I�ir� i�.. I���.f'i' 331rTL'�i i2t;i`T ;ITiGe..lili� 6?C?i�d�
SPA, :WAXX MALLS Oil DRNEW AY APPROACH.
CUST01A CONSTRUCTION 4116,4100 9F
POr:PAltC656. CIO Sy
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iC L'4,C�i-'LF7.A�� .i1F'.PuLL SIfMLV.iA�.•3N.'�d
CC,ARSTRUCTION AER 101 "'4.+00-41 9`000 $1i,5 6,04
P11AIV CHPAX FFX 101 1 R s i,w.61
MECHANICAL Mtn M56.56
FLE'k;'Ti r.CAL WE M -0001•420 -Wo $273.32
PI UMBB IM, F, 101=000 419-00I.3 I .O
S+TRS7M -MO '•ION Fee, R231O 101-000-241-00101 $36,29
C1I1+.M).1A O FRO, 101-000-42.3.000 SPSA!
GrF:b E OPF!R. IA PAVT FEE!-4k��,o 0
.ART rK PIALIC PLACE' • IDEM 2:70-0fI-445-000 94tr7.23
3
>, stf't;r1F�:C~`I+�
$6,M94
M93 11R.F.-RAIDMO
$10100
IVIALFEMOTIPIMS DUE NOW
sfa-19_44B
FEB 18 2003 U
CITY OF LA QUINTA
FINANCE DEPT.
OC) 41
ZD I
RECEIPT
DATE •�
BY` E AL INSPECTOR
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 . o
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 t !_ •_
P06 - .PAa
_
BLOCKWAL "APF ROVALS
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 , ,r^� _
Plumbing Top Out `/
Plumbing Final
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection -03 -7
Encapsulation
Gas Piping
Gas Test %_ ✓��%_-_-
Appliances
Final
COMMENTS:
_ J
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
ch
Final
Utility Notice (Perm)