0305-014 (CONR)F1
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
74800-1 B � � 04/30/2c
Date t I Signature of Contractor
-,t
OWNER -BUILDER DtECLA RATION V
I hereby affirm under penalty of perjury thatll 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 UNITED PACIFIC PNS Policy No. . N%Y:A119184.5.00
(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 withfthose provisions.
Date: Applicant9
Warning: Failure to secure Workers' Compensatioci coverage is unlawful and-
shall
ndshall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and a`ttorney's fees. -
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each pers
whose request and for whose benefit work is performed under or pursua A
any permit issued as a result of this applicaton agrees to, & shall, inde
& hold harmless the City of La Quinta, its officers, agents and employ
2. Any permit issued as a result of this application becomes null and vo if
work is not commenced within 180 days from date of issuance of s L.
h
permit, or cessation of work for 180 days will subject permit to cancellat on.
I certify that I have read this application and state that the above informatio is
correct. I agree to comply with all City, and State laws relating to the buil
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
J,
Signature (Owner/Agent) r Date, -
BUILDING PERMIT PERMIT#
41
DATE / VALUATION LOT TRACT
2860. -
,150A4
JOB SITE
ADDRESS 4
APN
OWNER, CONTRACTOR / DESIGNER / EN INEER
,.,S.6E•,C•aL! tlVAt.il.1.►: R. C1ViS^.6:.a7 _ 47 INEW `PYJ9A.X:L'l HONM ,
7161 t13I7W4AAVF_ 7161 D1 DIANAA'IAt
RI.V'EaMF CA 92504-RIVERSME CA 92504
(P99)'794-0840 CB1,4 5357
USE OF PERMIT -Vv
- HHERMIrAAaE€OOLBsIrMOcOC'ar01 COVE UPaAN •p.�
fOMMotfARF,A' OOLBUpSyNO(,kA$YA�4!-320$x1DIIi2�S) . .
�9A91.At9� 32G,U0 S�
ESIDWOM COW 11 CONSTkWlt<°Y O N
OXWAO
CONSTRUCTION.TEKE: 101 -000-4,18-000 890.00
.
PL.,AX CFi13'CK FV 101.000-43.9-318 $108.22
WIECk1AN1C.AL ME; 101-000-421-000 $23,00
XLEC d RIC,AL.M 101-00"20-000
PLtlAfih3PNG FEE ' '101.00p-419.000 $120.00
STROND Pl OT101a FEE - CO.MNI 100-000-241.000 X1.'33
OR&DING FEE 101-000-423-000 813.00
Alrr TN I+'LBIAC.PLAA,CES • COW 701-060-245-000 $131.13
"j L"t310'��t'f SG`17101 ANM X,)W IM CK
$421,76
USS PRXr-PMD.FEYZ
$0.00
KAY 13 2003 �a� �P�<� ��°.MSI rXr�
�1 M
CITY OF LA t�Ul..4TA .
FINANCE DEPT.
RECEIPT
DATE %
BYr/i
T FI {SLFjD
INSPE
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
t3 . p
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wail Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING Aff ROVALS
r,17
Gas Test
Electric Final
Waste Lines
fn
1
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX 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
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
R
I v