0403-292 (PLBG)LICENSED CONTRACTOR DECLARATION �
I ho ;eby_ affirm under penalty of perjury that I am licensed under provisions o
Chapter 9'(commencing with Section 7000) of Division 3 of the Business an(
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
? ; 6521,4 C42, MIC -2/29 05
Date f Y P 7" fl Aignature of Contractor
r . %I
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 t6 d6fttl'UN th6 pr6j6Ct (SAC. /U44, 131.191negS & I'YOIASSIOP1815
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
'1'ibi1�, 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 l!should become•
subject to the workers' compensation provisions of Section 3700 of the Labor
Coded shall forthwith comply with those provisions.
,,Elate:1 - I,k! rJ I/ Applicanti
Warning: Failure to secure Workers' Compensation coverage is.unlawfuliand
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 i`s
correct. I agree to comply with all City, and State laws relating to the building
�c!onstruction, and hereby authorize representatives of this City to enter upon
/the above-mentioned property f5pi6spection purposes.
Signature Date
PERMIT# * '
BUILDING PERMIT - '•
DATE �%� / •• .,VALUATION LOT 29 TRACT
t 21
f. , i C}tih1
JOB SITE / -
APN.-
ADDRESS 53 40.1 s VE-N.wl�S. w.tde�[tii
48^ 4
OWNER i
CONTRACTOR / DESIGNER / EN (NEER
IV1~.xEa
A.4 0x00L.%2-MCw, na-C
53-701 AVENIDAVIL6,°%
P. U. BOX 183
LAQ rA 0A X322.53
D.�L,,R!t`F:10'T8PMWG1. CA 92240 '
_.
(760):329-6675 CIBLA 0386,
'
USE OF PERMIT
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S!.'L.1vC`DN14F-C°t'/SIPP'6C:A13AND014M M
`y./i,i.,i).VI 1017 LS
ESTLIKAIT01) COST OF CONSTRUCTION
1'1,IPWIDNO ME 101-000-4•19.000 �3t�6f1
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MAR 1 '9 2004
OF LA
CIFINANCE DTY
E.P TA
U13- " 1l I t At;Y%2ti E1?~3t�7. Ij e%1 C n��OS�
$30.00
x ra<j PRE—PAW :£+'fER3
Tom
u TMAL i' 4 �' .� FZ S DDE 1\ OW
$$oyiD:430
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.
RECEIPT
DATE,' x! y r
BYI FI ED
INSPECTO
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
O.K. 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 - IM. 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 I
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
Final
Utility Notice (Gas) G
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Alain Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
8:43 POSTNET 760 776, 9695 4 92513405
COACHRILA VAL M V ATER DISTRICT
CASH RECEIPT DETAIL
Received From; - `• ( L'y =��s R � at
Addroe@: 360SIL /3YJ -
Account No. 1, ,Lo'tl/ei '
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meter(o)
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STEVE KERSTEN 41 Q
STELLA KENSTEM
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P.O. BOX 1441'f)JJAAJ Old 15
LA QUINTA; CA ILIUM Alt s'
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