0308-253 (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
/ 7:dt3I
B'111 1110 f. t 9>•3t AX
Date j'�'a P� Signature of Contractor
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 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
Section 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 �L)7 T�%PUk3I.1C $1dlf POlicy No.t7C:I�II?431i1
C (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 tlose/pyo, isions0
,
, Date: lel f/ a 'd_. Applicant % %%�IY�/.
dov
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
or 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
16 & hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued agla 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, or inspection purposes.
Signature (Owner/Agent) /����"•��/�lhc` Date jQ°>'�3"jib
BUILDING PERMIT PERMIT#
DATE VALUATION LOT -' TRACT
�1.61,7 1.20 21 a301:Z1.1
JOB SITE
ADDRESS
78- VIA PAVION
APN
" ��' 0�'�•�ll�
OWNER
CONTRACTOR / DESIGNER / ENGINEER
LEE NAR 3 OML-9 Cid' =.I3<OZ2I.3:iA
LWAAR HOWS C>1, C'AL1TA'ORPl'A
78--4t7I C HIG—T is AY 11 I
78.401 C° I 1TWA Y I l I
LA, mk Cid '92253
LA QUI14`t',Ik. CA. 922§3
(760,P77-0131 CBLR 3434
USE OF PERMIT
2�. C1 e • 17n�MI Y 1WIMALDIG
SYD n L &F'4' PL.AN:It.,Weasitt. PERMIT DOR-S'NOT .1TJCL,UDE
BL O ..' W-AL,_9, P004 SPS. OR D.RIV'> Vd''t3Y -APPIZO11MH
`IktP7.f`TAJw1:#311�"`I:f�?1 xiiS'�.0 SP
f=O'RCIVPATIO. 4991' at) We
(JAR.AOUCAet.POI' r 462.00. SF
3lPS �:TrI�D C,"OAeITL;IIF.COKI ..Tl?'UCTION
161,721,20
CONit'I'RUC1101H FL,E 101.000.4-II3-= 3061so
PLAN C112,CK �Bg $115.1-1110
ia9TlllU, ICAL F E 101-000-421-000 VIM
P-L.EC"rk11C:.AL ISLE $136.96
PLUMBINOFEE IQ:1-000-419.000 3I8A.00
S'TAi;3NOMOTION V22,R.ESID I0I•-•004)4AI-000 $16.17
0��.r��-�ay r>��c[; FEE. 101.000.423.000 $15.00
{ pip
l:°L"+Y S:•1.l..JS•'�l:r� i:�S�f'a6+1 •�IS�� �I.�9��:j.oY
U' '-TOTAL CC41MIT�CTIOIJ AA1Ct �T.H,ItT C�XEC`FC
,420.02
MISS PRE -PAID T47. �
$0,00
j
OW
YY �A�t PR'+SV.dYL'..L .FEES DUENOW
P 15 2'03
Y
CINI OF LA t�!�=FI .;
FIRaANCE DEPT.
RECEIPT
DATE
/
BY / `.� JEPLIE,0�/
IN ECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
_
Ducts
Slab Grade
_
Retum Air
Steel
_
Combustion Air
Roof Deck
1. 11-SWIP Itf-
Exhaust Fans
O.K. to Wrap
_ _
.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
_
Fans & Controls or
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
100, '
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
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
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
I
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
i
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
- Al