0402-232 (SFD)LICENSED CONTRACTOR DECLARATION
U I hereby affirm under penalty of perjury that I am licensed under provisions of
F— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
N W Professionals Code, and my License is in full force and effect.
O =1 License # Lic. Class Exp. Date
r,0LO
r --cc 77 99 8 4130/04
Z r iDate r✓ e.° Signature of Contractor
O "
J U CID
0 OWNER -BUILDER DECLARATION
HWW I hereby affirm under penalty of perjury -that I am exempt from the Contractor's
U) 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).
CY) () I am exempt under Section B&P.C. for this reason
LID
N Date Signature of Owner
O N
CL
z
WORKER'S COMPENSATION DECLARATION
p cc I hereby affirm under penalty of perjury one of the following declarations:
r � O () 1 have and will mairitain a certificate of consent to self -insure for workers'
X W compensation, as provided for by Section 3700 of the Labor Code, for the
m_J Q erformance of the work for which this permit is issued.
Q CD (,) I have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
? Z Carder Policy No.
ob 5 LIBERTY MUTUAL F +1dA�6100tt�47�30I�TC
(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,.! shall forthwith comply with thos provislo
,,.Date: Applicant°
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 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.
J� ignature (Owner/Agent)Date `y
BUILDING PERMIT PERMIT#
DATE VALUATION % LOT C1402_.'�2 TRACT
,.
30357
JOB SITE
APN
ADDRESS
O-77.5 EL DO O DRQVI�'
772-:.2-%Ol l
OWNER
CONTRACTOR/DESIGNER/EN (NEER
POLL BR()i' Mn" INC
TOT -L DRCIITMRS WC
73-12111=iNVAM1,4 r #100
73.121 FRL'i3 WAR -NO 01C0. . -
PAI -M DESWI CA 92260
PA-ZA T51w,MeC CA' ?2260
(71 60>674-9699 C,°r3 0 3632
USE OF PERMIT
St2FtlJr`-1DT 17,FytV-EN'r.ACiJ.�F,Al�'1rr�5it& i'�C�7MS NO'[P� rNCLUDE�
�t�{1Iq�Iy:I♦UT
VI., ICK l:A�dTA .C'00 yy s3I"A OR Ur E �tY.��al"P�.tr.�%���K .
CWTOM CONSTRUCTION 4,374.00 3F
PORC HIPAT.16 630.00 Sr
CAI',.AOFICrAR:PtORT 750.00 SF
1
4s4Jff 010 0011 tUAAgUM110
30*60 J 60
Ti' t uAmA ii7y
c`O1~ti;1TRUC'f ION KE 101.000.41 8.000 $1156154
PLN CHF.CIe. 10r.9 101-000-439-118 $1,262.45
MECHANICAL FEE 101 -000-42 $136,Sv
L".LWI'I4.ICAL FER 101-000-420-000 $209.69
P1.i311f31 HO FRE, 101.000.419-000 5713,00
Si.#2OHO MOTION FEE , RPZID 101-000-241-000 rm.3'1
0'".c" iNG FIV., 101-000-423-000 $15.410
r)L"i?pIV,A)PER IMPACT FEE 5.1,405.00
ART.IN PUBLIC PLACES - RESIT: 270.000-445.000 S400.22
S Pr• 0TAt. COMM UCI`ION fiND PLATT i°BEC'K
$6,261(,7:1
.LF103 PRi:�PlAiU FH'Ts.`�i
X0.00
f1 ® AL :4X8 Oita' NOW
U
MAR 0 4 2004
wr TY OF LA QUiN A
RECEI T FIN111
E BY
DATE FINALED
INSPECTOR it
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVAL•
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
_
Slab Grade
Return Air
Steel ✓
Combustion Air
_
Roof Deck
Exhaust Fans
_ _
OX to Wrap
F.A.U.
_
Framing !
Insulation
0M pressor
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 APPROV S
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
Encapsulation
Gas Piping
_
Gas Test
_
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring f7 y
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: