0303-271 (CCOM)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
I— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
C14W Professionals Code, and my License is in full force and effect.
O M License # Lic. Class Exp; Date
d
WBAC"
Z t-- Date Signature of Contractor
0.
JI.— CD"1-1 OWNER -BUILDER DECLARATION
H0
r— I hereby affirm under penalty of perjury that I am exempt from the Contractor's
Cn 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).
co () 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
o cc I hereby affirm under penalty of perjury one of the following declarations:
Lo 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
mJ Q performance of the work for which this permit is issued.
Q C) k( f) 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:
Nt Z Carrier ST.r YZ FUND Policy No. 1576131-2002
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 agr�e-tha its f I shouloAecome
subject to the workers' compensation' provisions of Section 3700 of/the,Labor
Code, I `shall forthwith comply with'those �,rovisions.
Date:r,A 2 /, i 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 applicator 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/AgeNn�t) `° ? Date"/_
-
`�
BUILDINGPERMIT PERMIT#.7
DATE VALUATION �Zs�� LOT TRACT
JOB ADDRESS 47-020 41 l'AS.i�t�iC3'�:ON SIIZLT
APN
OWNER
CONTRACTOR/DESIGNER/EN (NEER
Z:PP 19C
COLW J MC lrsV.1ZM_a1.'{YMC bi"OIT L. NMI
PO BOX 14447
PGS DOX 163
PAW.DESURT CA 92260
PALM €7Eu4"lv'RT CA 92261
((760)3415-0745 lBIJt 6,541
USE OF PERMIT
b 9'r 18' C,ai�PP0.R:fS. PEIRiiR IT 1JULS NOT IJVGL.Yl.UM115LKCTRIUAIi
pn ss,)
0.t`1M67i.5P4-..�'EY1.i-` IR M.00 214'
ESTE A"M COST OF COWl'&t:tsrt,�.:li.ON
1�,t3�12L�
FTJZW°c xt1KE V7bnalkay
CONSTRUCTION MI, 1.01 -000-418 000 $297100
PLAN' CH9CK ME 101-000-439-3119 $156.63
S'TRONO MOVON FEE - COMM 100-000.241.000 $6.00
ART IN PUBIAC PWC1,PS . COM) 270-000-445-000 $9.5.35
r sua-5Y? in CUgnpwafto 7' A1+11) PLAN
PTA2'•l1mC
$462.88
IM3 FRE-P9LDdW
$0100
-
TOTAL Ji',) M YZES D171N Y'TO'1wJ
�a
L
:RECEIPTDATE
_ .' °
BY
*111
DAT F ALE
INSPE R
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
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 APPROVA11S
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
Heater Final
-Water Piping.
Plumbing Final
Plumbing Top Out
Equipment Enclosure
-'Shower Pans
OX 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:
;Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
f9 / ✓� �/