0306-065 (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
Date ��`T Signature of Con tractor
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. hrOj?Prfy, im ayclusillcly r.nntracting with Iioonood
contractors to construct the project (Sec: 7044 Business & Professionals
Code).
() I am exempt under Section B&P.C. for this reason _
Date !9 < J� ` ' Z;11 Signature of Owner ��. s�. r.y] •• - t
WORKER'S COMPENSATION -DECLARATION
I hereby affirm under penalty of perjury one 1of'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, forlhe
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. M�yy workers' compensation insurance carrier & policy no. ares
Carrier ?3's'�t.` Z ARE Policy No.
(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 shall forthwith comply with those provisions. s -
Date: d ..; r = ri ?Applicant 111),�-
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.
Signature (Owner/Agent) �i'Le '' `' t t'" Date w '
BUILDING PERMIT PER;'Twp
DATE VALUATIONi.r.�LOT- TRACT/A.42
JOB SITE
VeJ�O 'l.
ADDRESS
APN
L"'h
OWNER /
CONTRACTOR/DESIGNER/EN INEER
t V L4,QLTW,F1.' 0., I1-1
1ta.iR7t.ly r,!:1w: ?pa t"aC,1wi'.if 3am, arra
200
QA 92021C.01dF
IDI 0A MW
USE OF PERMIT
isii KILB TOMMY ]CIM ilLLN 'h
•
:aa t) i.,O 9., M-4 )4 _ xImft5A t, ta g- �%
'W/?c`:,L,4 ''000 :, SPA CA 1,%ARrEWM1EjaT140mi To Pr: AM
CIii'iCIC.;f%'iw+E.0YJZT0'£,rlUI;;T1,0LE MtU,h0%iit":x,61 RA;i�'LAl, T i PM 30.k
C14ra3110M COWS'.) IVic T1 OA $ge ,40 OF
V14 0, U'
y
• EW,i U .3,-0 CMJ•4]T (11 0.2461'.i15.'k,v'4+x.t M
C0411Z11R ZCiiIQ4 TUB 1.01 ,f;i 448.000 ¢a11163100
>'i,Jt,'EI
NAMCHARICAIMM, M -00 -421 -ow V1113.50
Pi Q3 i1 C4:ist?F? 101
STY'.ol.40 MOVON ASI+. T.', JID lel-0-00241 -000
GRADWO FEEK
AuRT . C LIM.!C FLACM, RESSIL 2704 p'jO,44�5.,U,001
£EiZ-`1��7'I1 �y<"):4a 7.TC�3°t'Ci43'At+li3 fiIJ�f C?�^:.
,a1 !'x.9:3
D
Y '7 1,- ;1s MJW
JUN. 18 2003
CIFA : ..
ANCE DEPT
RECEIPT
DATE
BY '
gr FIOIALED '
ECybR
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
OX to Wrap
F.A.U.
Framing
Compressor
Insulation
I W
Vents
Fireplace P.L.
V
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
PWqjj-jnt. 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
D3
Heater Final
Water Piping
00,
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::
i s`a 7�;;/,a
/—� Ar,7� -
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)