0310-235 (PLBG)c• 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
WProfessionals Code, and my License is in full force and effect.
C) License # Lic. Class Exp. Date
r; W 490:341 C36:11.T
Z r- Date Si nature of Contracto
0
r-oO.�
CID
C) OWNER -BUILDER DECLARATION s
J
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ 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).
c•`)() I am exempt under Section
LO B&P.C. for this reason
N Date Signature of Owner
ON
0)
d< WORKER'S COMPENSATION DECLARATION
C:) 2 Z I hereby affirm under penalty of perjury one of the following declarations:
Lo H p () 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 U Q Section 3700 of the Labor Code, for the performance of the work for which this
11 rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
It z Carrier `TATL FUND Policy No. 166314541
Cb 5
C)
Q (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„�apner/so to become subject to the
workers' compensation laws of Ca1i{oqovia, ar�d a ree that if I should become
subject to the workers' compensati6/nision of Section 3700 of the Labor
Code, 19 all.forthwith comply wit�j/t@ ospro'rvisJo s.
� X Date: �a '%" d"Ij.JApplicant 1 rZ / i • / � � " ".
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section•3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
�1 any permit issued as a result of this applicaton agrees to, & shall, indemnify
map & hold harmless the City of" La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application hPromes null and void if
work is not commenced within 180 ays from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
/' i -
1 certify that I have read this applicaton a2d state that the above information is
correct. I agree to comply wit ,all City, and// tate laws relating to the building
construction, and hereby au orize represCntatives of this City to enter upon
the above mentioned property for inspecti purposes.
1
,,,I- Signature (Owner/Agent)Y`rt Y�M Date
BUILDING PERMIT PERMIT#
DATE } VALUATIONmwo5 LOT TRACT
o
JOB SITE
APN
�y�1V d ry- AT
ADDRESS %sci t�rcAAiB CbY0.F"1Q%4� ,sTLT111 13
OWNER
CONTRACTOR/DESIGNER/EN (NEER
WO P:RC;PFItIUS
:DRC 1?l.Xbih NNG Lir CO ACM ..i..&VATZZY .
47-250 V,"AMTK.1•iG•x'ON UIREE!
67-625 M011WA Y 11 Y
C1UWA. CA 92253
C�e.,,�3NDRAL C1•.CY M. 92234
k-760)322-7473 CBLO 4481
USE OF PERMIT
�r.•T.,fdr+d.�i�l�Y
11TST.A1,L. PLUMBRv0 Rif PR. PARAT',C9N FOR TH?i1ANT 1,MPROV•EME T.
VALUATION iy
R:r"F'.PAi'L'$ D 3:i?�►`�?' OF Ci9Mf".�R4,170.N
.FER1911 'r!iy SUMMARY
PLUMBING FER 101-1300-419.000
PLAN CHgC:F;:1?'E;ir MAO
OCT 12 2003
CITY 0�• .JA OUINTA
FIN _= ,r CS DEPT.
SMI-IX)TAT COli.1'.%R 014:P NP PLAT' CMIMI
$102.50
LESS PRE -RAID 111-1
$0,00
�
RECEIPT
DATE .- / -�
BY,.-'-
DATEFINALED
INS 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
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 APPROVALS
Steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I I
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 Q
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:.