0305-244 (SFD)LICENSED CONTRACTOR DECLARATION
d hereby affirm,und'er 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
e�##q A y�g
Lic. Class �! Exp.rDate
0p gyp.
Date ; � t '"Signature of Contractor � 1iif I L rN4—Y
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 structureis 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
Se'• ion 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 NAT IONAk,111+1IC+7id F Policy No: 77033309.
(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, andAgree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with'those provisions.
Date`:11 (; t :' t 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 andJSafety
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 pursuantto
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
f
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,., a nd State laws relating to the building.
construction, and hereby authorize representatives of this City'to enter upon 'i
the above mention ed p operty�forjinspection purposes.
Signatu a (O� nef/Anent. ••+--"Nlll�, •A�P -- -' Date •�i iw
A tl
BUILDING PERMIT PERMITN
DATE VALUATION q-- LOT tAW254 TRACT
JOB SITE
ADDRESS C�;; U WWW0J 4- -COM
APN
7"2i7(.a Q!7
t
OWNER
CONTRACTOR/DESIGNER/EN (NEER
SHEAH.OMIS FOR AC,'` VE ADULTS
GBEA HOMES
60-311. IRD.,00Y PARKWAY
'S 1 - 2 6 0 AVkA►,T UA 62
,iaAC t1WA CSA X2233
'i'>fiwRMAL.
CAA 92 353
(Q, 09)833.,8996
PMA € 876
USE OF PERMIT
WILE P;Ml,[ Y DWELL—wo
SFt] • 1'77 la.f.,V4 4520A. 'PER 41,' r.IOZS 1107` f10CL009 FILOCK WALL%
POOL, SPA OR DRIIVYWAY APPROACH
CUSTOM CONMUCTI.ON t,moa 8F.
FORC UIPATIO 177.0 SP
0AARAMC9A>'r PORT 438M 3F
'%MATM) 'C UA' OF CIONS'.CRUMON
143,2.80A0
PERMTOTE SUMMARY
COAiO'.l:WCTIOX FFX,. 101.0100.43 S-000 5�9 .9t6
PLAN e'vH.ECK FEP, .101-000-139-319
MEC;IaIAN C^AWeE 101-000421-000
ELECTRICAL YZE 101-000-410-000 $102.34
PLUMBING FEE 1.01-000.419.000 5122.75
STRONG P.40TIOp1 FEE • lrtl011) 103 X000 -PA 1.000. $14.37
GRADING F>s{I 101 �OOQa�l2'3a0f)t1 $15.Iiti
DEVELOPER MPACT FFY '62;411S.Qt!
GUM ..^(t3F [, 4:. 'i7G`"r'ICiA1 fs PLAN f :" - :
4'168.29
r L ISS fPJ B—PALI I1 3
$0.00
. 0TA1,-,1�FJ?Ad1 T FXXS DUE NOW
14,168,29
c
JUN j o 2003. ►
RECEIPT `
DATE f' t
BY tl
FIN ✓��
IN
CTOR
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
F.A.U.
Framing
Compressor
Insulation
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
p
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Piaster
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
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: