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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 a,d
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
AV� JxtDate Signature of Contractor ` *f
s f �
OWNER -BUILDER
I hereby affirm under penalty of perjury that I am exempt from `the Con`t"ractor's
License Law for the following reason: \-'11
( ) 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.
(, s) 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 0 i ATP FUND Policy No. 1353110-010
(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, andt £ ree; that if I should become
subject to }hew rkers' compensation proviDs� f Sction 3_7,00 of�the Labor
Code, Is�!;all o wl h comply wiih those provision G+'" %�
i
Warning: Failure to secure Workers' Compensation coveraged is u lawful 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 Buildn g 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 toycancellation.
I certify that I have read this application
correct. I agree to comply with all City,
construction, and hereby authorize rep
the above-mentioned property for,inspe!
/Signature (Owner/Agent)
state that the above information is
State laws relating to the building
�tatives of this,City`to enter upon
pu rp �'�# F"� o.
Date � t
B,UILIDING PERMIT 1s PERMIT# ;
()�I
DATE VALUATION LOT TRACT
12/03/%1£ slopoo
JOB SITE
APN
ADDRESS i` I CF,,UB I:.)VE
OftER
CONTRACTOR/DESIGNER/EN (NEER
/ SUN VWAT'JEVELOPM-Wr CORP.
&R. BRAY CORP dba.r-0ilif0Z PLUS
!!! PO BOX, 1144
681 & PARYMZ U1'+,�`1� 00
LACaI:MTTA CA 92233
ORANGE CA 92868
014)764.0020 MIX 1881
USE OF PERMIT
ETLEC1.t21:C,P L
TEMP PCFWFR. P01.8 Z 51111 POLFS
VAT,UA'1ION E00,00 LS
EAMATM C+OS".ICOla, C°{)MIR1: CTrOId
100.OD
EWIC RICA!,, FEE 101.000.420.000 $45.00 .
":DEC 03 2003
CITY OF LA QUINTA .
FINANCE DEPT.
ISM -TOTAL CONErrR,UC'IiUi4'PND :1'Lhw 1_'FWC.K
$45.00
LESS PRE-VAID MMS'
$0.001
TOTAL. PER N@6"!['I+FKS DUF 1+30W
&A5,00
'R�EIPT
i
DATE
BY
DA FINA
a3
INSPECT
.i
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 - Int. 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
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
'Nater 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
Law Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
6 MONTH RENTAL.
.SOB ID: 130425 DESERT CLUB DRIVE AN
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D CALLS AMIGO
' SUN VISTA
DESERT CLUB DRIVE
VISTA DE MONTANA
L-A QUINTA
SUP: RICHAF
760-678-14
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' SUN VISTA
DESERT CLUB DRIVE
VISTA DE MONTANA
L-A QUINTA
SUP: RICHAF
760-678-14