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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
777695' 3I 4/30103
Dat Signature of Contractor Ia
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 i,1BEI%T FtlUTUAL . Policy No. WA261DOOM301M
(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 sh II foSthwith comply with those provisions.
Date: Aja Applicant qAM Z- e/ c " -
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 tiffs
application. k,
1. Each person upon whose behalf this application is made & each person 2t
whose request and for whose benefit work is performed under or puisuant 3o
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),,12 % h Date
BUILDING PERMIT PERMIT#
fX102,10-2 )aa
DATE c VALUATION 310 LOT
LOT 17V�TRACT d03 77
f
JOB SITE / / -`"' - ^ si >
ADDRESS
1
APN
OWNER
CONTRACTOR/DESIGNER/EN INEER
'#X01:1 f32OMIT.ERS DIC:
I."OM I.TiiJ`Uil RJ;114C:
'74-. 3 Hf?WKLY 1AM? r- M=2.220
74.923 TIONYMY i.AR
PAf..M1:5RIMcT (M 92260
P"i A MBEIG' (:A 9226.0
(�.76Y0)674-9699 CBL -ft 3832.
USE OF PERMIT
MIG -LB YANMYD.WMZ-[NG
3,n) e L-17 -Af SA14T:ti ROSA •8. PERM. IT 1101193 NOT T00-AU.DS VLOC X
w. LL4P001;, >!:PA OR DRIVEWAYAPPROACH, 75% R EDUC°;'j 109 TO PLM,
CH"E.t.X FEE DUE TO XtU1,.4•iPLE IS xL7.ANCt 01? SAME I ILKH i"! PK
- CUSTOM CONDTAVCTIOW 3, 41.0 P
PORCHl1?ATIO 321.00 Sle
(11AAAWCANPORT 756.00 S
rte 7A ED i;On OI', C;C?N5"17 UC 11011'
C"`ONIZ11''I'tUCIP Oi Im 101-0 0-418.000 S)'YAN,
PLAN CHM11C 101-000-059-318 $7.A-0
f�f�%C7'YtICiA �a .`a�� 101 "000"426/^000
PLUM13IN0,1 9 10-000.419at3i1U $190,00
S3 ONO MOTICYN PRO - RE,`= 101-0ZS,,43 -000 101.05
<9.PUADMO t�'F:1t 101-000.4 ,-C.1Q %f,.5�CIO
DIY LSI„ APS R IMPACT F'F'1 z $2,,twxm
ART IN PUSLsC PLACES - ii.MIT 2' O -t 00.445-000 SM/6.32-
7. 7 • _ n s ." %1•a�.T'37UC: TION 1A14',1) FLAN y:(i?rIX
$4,€ 93.70
LE33 MB -PAID PMS
"O.00
OCT 31 2002 10� :9� � TDOES .��OW
A9,10
CITY OF LA QUINTA
FINANCE DEPT.
J&
RECEIPT
DATE
By
D E FI ^ INSPECTOR
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INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings E Z,
Ducts
Slab Grade
Return Air
Steel 17
Combustion Air
Roof Deck ZZExhaust
Fans
O.K. to Wrap 0
F.A.U.
Framing
Compressor
_
Insulation
Vents
'
FEE
Fireplace P.L.
Grills
_
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
f _11—
_
Final _
POOLS - SPAS
BLOCKWAIJ 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 AP ROVALS
Gas Test
Waste Lines
Electric Final
eater Final
_
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer lateral
Pool Cover
_
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures i
Main Service ✓ _ Q
Sub Panels
Exterior Receptacles
G. F.I. /
Smoke Detectors r�
Temp. Use of Power
Final
Util itY Notice (Perm) ) S- .03 �