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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
77'7699 Ph 4130A
Date Signature of Contractoro, • _ r0+i�'�^'"""`
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, as provided for by Section 3700 of the Labor Code, for the
performance of the 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:.
Carver ,,IT y 1bii37'LfAu y Policy No. 1W.f.,MD0047230127t
(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 fo hwith comply with those Prov Ions.
,Date 2-Zz—Z. ga Applicant/{i?
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to tithe conditions and restrictions set forth on & his
application.
1. Each person upon whose behalf this application is made & each persoi at
whose request and fof whose benefit work is performed under or pursuantllto ;.
any permit issued as a result of this applicaton agrees to, & shall, indemnify
J� & hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
• correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
i
' Signature (Owner/Agent), �!.� `"" "'" Date
BUILDING PERMIT PERMIT//
DATE VALUATION F1 LOT �- - TRACT
Va7v %
JOB SITE
ADDRESS �.�`�e �7TZ,e�z��Yi�s
APN
OWNER
CONTRACTOR/DESIGNER/EN (NEER
`I'01.111 S3.Ra3.i,ITIM WC
TS.iM BRO?'T111SI S 1%TCr
73.121 MMWOU1`7fr#100
PALM DE.817 ..Yt' CA. 92,260
PALM ,.ri`,I.ZT X11 92260
(160694-9,6199 CUR.3832
USE OF PERMIT
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$FD - WT 164% S"TA R ,tel it., MRMIT 000 7401' MCL,U IM
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C ONUTRUCT10'Ai WE r U1.000.4191 -000-419-090 $113.00
PLAT4 i."HJXX „t"1;E 101-000.439-3•I a $ISIIZ.�f+
MrX'1lAaNICAL,FEU '1011000-421.000
Si.A 6 RIVI'iL, FEE 101-000-4120-000 002.08
P1:UMBIWO FR9 109-,001-419.0004 %190.00
STR:OW0.140.I*ION ME - ix.&M IM -000-241-000 a3F.3f.
OR.&DINc.1,ER 10i••000-423.4010? Vigo
DZY'E1OP1111 R,IMPACT VLId?
ARS` iN k'isBUC PI AC113 - E 270 -OW -445-000
C`.X
$5,744.43
E& i'FJ.-PA10 PE'8S
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PE RMY 111rXIS )MME 1101W
$5,744A3
2003 '�
OF LAQUINTA
CITY
FINANCE DEPT.
RECEIPT
DATE
BY;
DATE FINALED
INSPECTO
,,
_
/)
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings4
=77Ducts
Slab Grade
i
Return Air
Steel
Combustion Air
Roof Deck
Lf.
a3M7
Exhaust Fans
0. K. to Wrap
, o S
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
_
�r IC
Final —
Final
- —
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
6 a 5
Heater Final
Water Piping
17
Plumbing Final
Plumbing Top Out
/� �%
Equipment Enclosure
Shower Pans
v
O.K. for Finish Plaster
Sewer Lateral
f
Pool Cover
Sewer Connection
6?j
Encapsulation
Gas Piping
Gas Test
Appliances
_
-
Final
COMMENTS:
Final C`
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
Finalo
Utility Notice (Perm)