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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 and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
Date 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).
(y� ))I, as owner of the property, am exclusively contracting with licensed:
coo"ntractors to construct the project (Sec. 7044, Business & Professionals
Code).
() I am 9xe pt under Section B&C for t.A reason
Date . s ) Q Signature of Owner . ....u,
I hereby affirm under penalty of perjury one of the following declarations:
() I have and will maintain a certificate of conseni�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 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 I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall fgrthwith comply with those provisionse s
Warn h—g:'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 alresult 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 authorize prepresentatives of this City to enter upon
the above-mentioned Dropertv'for msDection Durooses.
11 Signature (Owner/Agent)
Date (,2 ". %
BUILDING PE_RMIT., PERMIT#
DATE VALUATION LOT TRACT.
Mn rtfx: =101111
JOB SITE '
APN
ADDRESS
I
43-785 GALAXYDRM
E
OWNER
CONTRACTOR/DESIGNER/EN (NEER
RC?N WHAT
CaWNER BiBUX)FIR
4i 40 GALeMY
1.,kQI)1bFj A tiA. 922,53
USE OF PERMIT
WWRILANDOtM
ML.1'j:S 0MCM, i:':OdvVERSION TO BONUS R,fit:3:M
C4" I)Lt` §304.5 PORIWORK DVOU14 WITHOUT FHOUT SU°,1<I3MO PIrXAQI ,.
30MAI C051'OP P CONSIRUC'TION
MUD
WESTI'(My,]OP MalaO nAI7 h7= ' attgi}, SS ,P
t JUN 2:2 2001
CITY OF LA OUhVTA
FINANCE DEPT
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!MS PRE-PAIDF MZ
$0.00
I'L.�'.�ALTIMM 1I`TX5 OUR NOW
RECEIPT
DATA[1 r
BY
DATE FINALED
INSPECTOR
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 1.
Final [O_ZZ: f
BLOCKWA.L s APPROVALS
Final
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
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
Fixtures
Main Service
Sub Panels
Ekterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility 'Notice (P�jrm)
COMMENTS:
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May 29, 2001
To the City of La Quinta
All Departments
To Whom it May Concern:
I Ronald Walker to authorize Jon Dunlevie to act on my behalf to obtain permits and request
inspections of my residence, (43-785 Galaxy Drive, La Quinta) as necessary for the purpose of
obtaining final signoff of permitting or obtaining new permits for bonus room, (office area
permitted by original builder through city).
Sincerely,
Ronald Walker