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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
771699 D
Date3 �`- Signature of Contractor's'/
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:
Carrier LIDE11.'T Y MI) TUAL Z Policy No. ?1A262VOC ?2S0127f
(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 orthwith comply witb those visio„ns.
/Date: Z 39 Applicant • 004
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 hi§
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, indem
& hold harmless the City of La Quinta, its officers, agents and employe
2. Any permit issued as a result of this application becomes null and voi
work is not commenced within 180 days from date of issuance of s
permit, or cessation of work for 180 days will subject permit to cancellati
I certify that I have read this application and state that the above informatio is
correct. I agree to comply with all City, and State laws relating to the buildi g
construction, and hereby authorize representatives of this City to enter up n
the above-mentioned property for inspection purposes.
Signature (Owner/Agent). - ' % "”' Date
BUILDING PERMIT PERMIT#
DATE VALUATION $362099.002099.00 16'3 LOT � TRACT
�.30357
JOB SITE
ADDRESS .7R�-w✓JA �,sfA�t Vh1d xx}
'
APN r lM.�•�911
OWNER
CONTRACTOR / DESIGNER / ENGINEER
x � ILL BRO`1 E i` l'c"f'Cx-
F.BROTHEIRS I V
73-3211 MI M WI AM. OD
'71.1,21 nT_"D W P'1 G A100
PALM DESTRT CA 92211010
PALM DE T CA 9`%260
tt`760)674.9699 OVA 3K42
USE OF PERMIT
M('3LJy, IrVALY DVILUX90
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Mt1`1' iN 1)UE'; O MU131PLE 1ZS$U.1,U4t E Olt MWE DIAL TYPE =
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PORC'i^ WATIO -r 650.00 SP
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MM" M SUMMARY
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P1fi1'�'�i 5.01E7;.•?w,11.11.•.t • 101- "k-439-318 $131 2.61
mrrl1."W31„L F-0-1 101.000.421-000 Sg66110
f?1XVI T15.iCAIL SZE 101-000.420-000 W1 X9
PLUM 1ri' G IFTY 1.0'1.000.419,000 $213.00
S t w0,401U OTICTtd KIW, - RM, ID 3111-000-241-00,0 $36.29
c1RADENO KIR 101.000,42.3,000 515.00
f EVE—f,,OPIM IMPACT 'k ELO $:440s.01'+
AlUr IN t?i1MIC PLACES - P M1L 270•>43+'0445.000 "07.22
SUR -1 01 AL COMM 'Id.'T Y I-1013AND 1,a1'..A1.eY C5 WXX
TS,1.3 ;x.2.3
_... XX33 PRE -PAID FEW
$0,00
FEB 1 g. 2003.4
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CI A*>
FINANCE DEPT.
RECEIPT
DATE
BY
DATE FINALE15
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
Exhaust Fans
O.K. to Wrap
3 S
F.A.U.
Framing
Compressor
Insulationa
3
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
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
Water Piping
Plumbing Top Out
o
✓®
Heater Final
Plumbing Final
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
-0–, 57
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final _
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit —O
Rough Wiring % ✓ /
Low Voltage Wiring tt! v
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) I���
COMMENTS: