0108-292 (SFD)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
5/3 V03
Dated `'"Signature,ofContract", 1
......._-----OWNER-60ILDER 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.
(�,)o 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 Policy No.
21~WIT1712469. Co. 7,042394MI6
(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-oflSection 3700 of the Labor
Code,C4sh4[llforthiwith comply with` thossee,pfo—vis n ff
Date:' •r`{{" .� APPlicaryt,M..
" 'Vllarniiig:`Failure to secure W,d"rkers' Cornpehsation coverage is unlawful and
shall subject an employer to�riminal 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 author'z8 representatives of this City to enter upon
the above-mentioned property for inspection purpose
Signature (Owner/Agent) Date
I
BUILDING PERMIT PERMIT#a
DATEVALUATION LOT `- � 0,06- 92 TRACT
/"
20,78t3�s 0 4628444
JOB SITE
ADDRESSM 78
�r� WM r1yP
APN
OWNER_ —
CONTRACTOR/DESIGNER/EN INEER
€ APS":['�:.3:�t BF! G VY t �:�'" T', ILC;
1`�:i13f:)�t AI E MORT <.;0M&MTXY1U--;,INC-
2 0 ?} 1J P3 +7CrT+�� S �9'V ; w lis i fJRI .
200 X WA tWIAMO_hd AV)}' 41 On
� `C33FI� iS r CA 92,025W;C+ND)K�
0 CA 92025
C.TL* 5413
USE OF PERMIT
SI • I=e;.,:A'Nt .UN 'LOT 45- PM -AIT TICI ,;a W0 T )1NCL,VDX POWSPA,,
01,010K WALLS OR €� 33W.#%Y APPROACffi
moo r —__--T---nn_nn]
CUMM, COAMUC ION 3JAW0 OF :' �LAUG
2 9 2001
PORC°HVPAA' O IM09 SlY
C4.t1.i3'�'OEICARPORn T 00 SF. i CI
FINANCE
OF LA QUINTA
DEPT.
13s"mal,° 3 iJ' OF 6:701NW
320,7W.60
COIAS`2`RUCTIMI FRe 101.000.418-000 S4,�i1.04
Pl.Ai, l C,'HFICK. XVII, 102-000-439-313
MECHANICAL FRE 101-000-421-000 $14.l,Rtll
ELECTRICAL IWr 101-000-4,20-010 Sii3k.le
1'=Lit►MBINGl FEW 101-M-419-000
i'gETxmo monoN Per - RESIT) 101-000-X41-f1t.1G
0111A INO WE 101-!000-423-000 $zn.aQ
INTIKASTaaUCTURE r,1, 225.000.443-342 $l,l?lii.1�8
ART W PUBLIC PLMAS - REDS 270 -OW -40—M $301AV!
"�S 'PRE -11 -PAX..) .F.T F'S
T11),10 0
1
RECEIPT
DATE
,�, ,i, y {. f
BY
D E �lVA DR
I2,/�CTO
INSPECTION, RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs _ _
y -/�
Forms &Footings��—WMIE—
nderground Ducts
DuctsSlab
Grade
(�0
Retum Air/_D
Steel
Roof Deck
_
Combustion Air
Fans
- —
O.K. to Wrap
y �� .D� _ .��
F.A.U.
W
Framing r`
Insulation
3/ l _
_ �� �� _
Compressor
Vents
I _ J
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
-
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
�_ -
/ �
Final
J
— /'---U-�— —•-
Final
--�— -
I
-- "—'— — —
POOLS -SPAS
BLOCKWALAPPROVALS
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
Waste Lines
�6r - i
Electric Final
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection/��
_
fj
Encapsulation
Gas Piping
Gas Test
/VN_
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
'—
�� 143111 5;
ELECTRICAL
APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voftage Wiring
Fixtures
Main Service
Sub Panels
/
Exterior Receptacles
G.F.I.
��
Smoke Detectors
Temp. Use of Power
Final
Utility Notice
1
(Perm)