0403-324 (RC)LICENSED CONTRACTOR DECLARATION
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
t14 W Professionals Code, and my License is in full force and effect.
O M License # Lic. Class Exp. Date
LO
"...o Z
/Date Signature of Contractor
CD 0
J U C:) OWNER -BUILDER DECLARATION
HWd I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) 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)
Q WORKER'S COMPENSATION DECLARATION
CL
p cr I hereby affirm under penalty of perjury one of the following declarations:
U-) <O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W LL compensation, as provided for by Section 3700 of the Labor Code, for the
m� Q performance of the work for which this permit is issued..
Q C) ( I have and will maintain workers' compensation insurance, as required by
D Q Section 3700 of the Labor Code, for the performance of the work for which this
li.0) H permit is issued. My workers' compensation insurance carrier & policy no. are:
Z Carrier PEIIFERUD ELPIA)Y Policy No. tNK2d'409040.2
aDry�-y
V
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
subject to the/ workers' compensation provisions -of, Section 3700 of the Labor
'ode, I -shall forthwith comply with those provi'slonsj
Date:. -5! i! LJ ( 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.
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 authorizes representatives of this City to enter upon
he above-mentioned property for inspefction purposes.
Signature (Owner/Agent) �3%' «f j -, c ` ��--� Date
BUILDING PERMIT PERMIT#0403-324
DATE f VALUATION LOT TRACT
iF iC'Cti�1
10y]K4JOB
SITE
ADDRESS ..�1�.-Q.`�.�.(r�.%�
APN 7i �'—iriY•Y
OWNER
CONTRACTOR / DESIGNER / EN (NEER
BOB EDWAt"MS CONS UCrION
PIOD L`Dw.AiZ.Ds COMI IRUCET(`N'
79-9201. 3.MMA DRIVE
79.920 I7MA 1YRIVE
L& QTJDUA CA 9225:3
LA QUI TA CA 92253
f 1u0j7'75-' 933 G`;Cilalf 3212
USE OF PERMIT
L:071af. AM. (.. XL RR'MO}J�.
CORH'isd1:FtC1,ttiL If;L%M017'P+•L �10FFICE RWY01; EJJ OCCU.PA14T LOAD 23, TYPE
VN, "On OCC WP ANCY 200i CDC, 111VE 3TIOA'TION I•`EE IMPOSED FOR
COM.�,'ILMC:.It4G WOPli MORTO ODTAiN ldCT .fi 5UILDINO PER MIT.
VALUATION 10100100 LS
CO'S".k Oaf` C0JtiTMZUC'T1'0N
yESTWXXKD
S'��asRJv�A C2.",,t'JAin iI M1ATJI.�IFC.EJ
.
NAN WiRCK IEE 101-000-439-31S $76.03
CONSTRUCTION F?R 101•-000-418-000 $1117.00
ME UANIC.N, FE9 101,000-421-000 sf%s 1
V,IX'. RICAL FM_ 101-000-420-€'i00 $35.40
PLUMOINO YEE 101-000-419-000 333,00
STRONO MCITION 1IM - CONINI 100-000-243.008 $10
i' �5tE;TTWATION FEE 301-000-423.000 gait0,4a
OTL1B-1O'TAL C0,1,= RUCUTOX.AND PlAW CHECK
$564.00
LESS P'Zr E-PAWMS
$0.00
MAR 3 0 2604
CITY OF LA QUINTA '
FINANCE DEPT. -
RECEIPT
DATE
V
DATE WALED
INSPEC
3 '' o �K
- lir! t
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR M,
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
O
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
BLOCKWALL APPROVALS
Final
Steel
POOLS - SPAS
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
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: