0211-167 (AR)LICENSED CONTRACTOR DECLARATION
f. U). 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
c� W Professionals Code, and my License is in full force and effect.
O =) M License # Lic. Class Exp. Date
O 777699 B 4130/03
cZ r-- 'Date A!144 Ai Signature of Contractor✓oo--
CD 0. Ci
J U cfl OWNER -BUILDER DECLARATION
LU LU I hereby affirm under penalty of perjury that I am exempt from the Contractor's
CL
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
O N Date Signature of Owner
rn
IL z WORKER'S COMPENSATION DECLARATION
C:) CL I hereby affirm under penalty of perjury one of the following declarations:
U') FZ O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W compensation, as provided for by Section 3700 of the Labor Code, for the
O _ Q performance of the work for which this permit is issued.
C13 Q I have and will maintain workers' compensation insurance, as required by
O U QSection 3700 of the Labor Code, for the performance of the work for which this
) Z permit is issued. My workers' compensation insurance carrier & policy no. are:
'It:Carrier .WF3ir;RTY MiJ7''LTAL F Policy No. 'ATE 262-D0 4"&,012TI
ob5
� O .
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
3 subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
,Date: !_ Applicant-_ Qk) z:, Z;---
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 emploFpin 2. Any permit issued as a result of this application becomes null and v
work is not commenced within 180 days from date of issuance of
permit, or cessation of work for 180 days will subject permit to cancel)
I certify that I have read this application and state that the above informat
• correct. I agree to comply with all City, and State laws relaiing to the buconstruction, and hereby authorize representatives of this City to enter
the above-mentioned property for inspection purposes.
Signature (Owner/Agent)h), Date _
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
S?R4>9aN(i Ivy 3fiy�7
ra ,
JOB SITE . �-
ADDRESS 1VVNU__ 159 ' D0%W0 DRT Vr,
L
APN
-
OWNER
CONTRACTOR/,DESIGNER/EN INFER
°!:C?iai,.I RR(71 bM1g1 S TAC
T01.1LIwWr+WII S rNIC i
(10,0)67--,5699 lJi 38w
USE OF PERMIT
Z�� r . )TI -11 ., ADDIrIl:1
.SOPP11tPMEN'3 AI, TO f FRI61I`t` # 0210440% ADDINO 30Y ::.F. C,AS.I3'A TO
IIE'SIDE Clt'(.fAiWRR 0014VTRUC ION (USE S.FD JOB CARD)
CUSTOM i.`f: NS't'R.I7C'¢ION 2.It11.00 SF
WUMATCD CO;S E' OF c.'01%V_RarCr10K
23,993.20
CONSTRUCTION YBE 10l -M-418.000
PLAN Ca VCK ITEM 101 -000 -A.:39 -•.31€i
WC:1"ICAL TQC 101.-000421•>000 $47,00
.RLI CTIUC.Pal.. FFY, 101-000-420-000 $25.141
�
PIlu M DIN %114 M 101 -000.419-rXIO $36.00
:5'fRONO MOTION FW, IZMD 101-000-241-000 $2,40
- —
:illi-Tt7iA CO 'i2ti'f,�t.IONT,f3,ND X.i'1:t�• (211"WK.
$115.12
idi�[u PPJ3-PAID 1-4=
$0,00
s I�G TAL .P�.��aiff .1• 'St . In �`�'€3�+V+V
I$S,:f .2
DEC 0 6 2001
I0
TY OF LA QUINTA
DATE
BY
DST$ FIN A
I PECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
- (tel
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
_
Exhaust Fans
O.K. to Wrap
: CO)
F.A.U.
Framing
Compressor
Insulation
, o
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
— -
POOLS - SPAS
BLOCKWALL A PROVALS
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 3 — -
Encapsulation
Gas Piping
Gas Test
_
p
Appliances
Final
COMMENTS:
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
_
Final
Utility Notice (Perm) EE
_
-k
fiI