0403-021 (SFD)LICENSED CONTRACTOR DECLARATION
U) I hereby affirm under penalty of perjury that I am licensed under provisions of
H� -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 =) M License # Lic. Class Exp. Date
r-763187 B _ 5 3 110
f -
Z P ibate Signature of Contractor
CD 0.6
r- U OWNER -BUILDER DECLARATION
Ha I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) License Law for the following reason:
Z_ ( ) 1, 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, oo owner of the properly, am exuluslvely CCntradting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
C'`) () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
ON
0)CL Q WORKER'S COMPENSATION DECLARATION
C:) Z I hereby affirm under penalty of perjury one of the following declarations:
T H O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
m Q I have and will maintain workers' compensation insurance, as required by
O
C Q Section 3700 of the Labor Code, for the performance of the work for which this
d rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
co -5 ITA -TE FUND Policy No. 1088263-02
t` C)
J(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, I shall forthwith comply with those provisions.
Date: 2- `% 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. L
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
th
e above-mentioned property for inspection purposes.
Signature (Owner/Agent) `�Y• �'✓ ��.'rr Date lam" "�
BUILDING PERMIT PERMIT#
DATE r . V LUATION LOT 0403-021 TRACT
3, , 7, �'
}� 1 289451
JOB SITE
APN
ADDRESS &W5 WIMCTW MOOT
775 -3x) -EZ l
OWNER
CONTRACTOR / DESIGNER / EIV (NEER
C -AV I-A...yQ/�VII�1��'yT�.kne�'�U��[:t�Ay}q
rlr�iyl� 0V�{R,ri/`�;:tiyt[, lty11�;�4' ja C�'f/.��+h�Mu':1�1nIES, INC.
t� �
200R. ♦'i AU:�.fA."@4: ON S' VF. #100
200 F_ �'Yd 1VJG.lY.i°(\.T (M AVF_ 6f10 0
ESCOAbou)o CA 92025
FJ4 C`0NY.e1D0 CA 9202.5
('760)835.8238 0711 5413
USE OF PERMIT
11
S1r1J WTI, PLAN X. P'=41T DOkY.5 N10" INC1. IDE BLOCK '`wrALL%
P001,, SPA OR DRIVEWAY APPROACH
CU42' TOM CONSTRUCTION 3,498.0+0 SF
FORCP1/!sA.TIO 740.00 SF
0AR.At3 CARPORT 660,00 OF
LWIMATKO Cosi„ or, CON91R.UMON
294"9.60
C01403f'RUCTION 1•EE 101.000.419.00 S $1,322:00
PLAN CHECK. FEE 101-000-419-318 $1,15W.49
MECHANICAL, FEE 101.000.421.000 $1,13.50
IELECTRICAL, ". S 101-000-420-000 $210.2a
PLUMBING TITIF 101.000.419.000 $1'79,29
Sf ERCYNG MOTION PEA' • RE.`JD 101-000-241-000
C RA -t 1 40 FEE 101r000-423-000 ' S11100
DEVELOPER IMPACT ME $,!k4G. 00
AR7' M PUBLIC PI. &CES - fMil 270-000-445-000 5236,10
IRM�ly'J>y)�►,
$5,619.48
( (� y��( �
PRE-PAID
I
/
'DOTAL :k"L RAI TC 94 ELS DUE NOW
0,619.48
MAR 18 2004
2
CITY OF LA QUINTA
FINANCE DEPT.
RECEIPT
DATE ^ t
I '�
BY`?'
DATE FINAVID
117---316
INSPECTO
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts • _
Forms & Footings 11,16 y
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck (o `/
�cam
Exhaust Fans
O.K. to Wrap /
F.A.U.
Framing 1
Compressor
Insulation 4V—Z-& z2W
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath /b
Drywall - Int. Lath
Final
Final z3
POOLS - SPAS
BLOCKWALL AP ROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
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 A
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test /
Appliances
Final
OOM"ETS
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) OR