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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 i
Professionals Code, and my License is in full force and effect. -
License # Lic. Class Exp. Date
770940 (39 R(C
Date '- " �' Signature of Contractor�j��� b • .2
OWNER -BUILDER DE6s�11- ATION
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 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.
00 1 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 ru,(' F't,"m) Policy No. W"114-02
( ) 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 with those provisions.
Date: -5-X- 4, ^G Applicant ='a d>. • --
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 af
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
correct. I agree to comply with all City, and State laws relating to the buildin
construction, and hereby authorize representatives of this City to enter upo
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) t. ��'• •cc 5� Date 5 "O -!1
OF
BUILDING PERMIT
DATE W0111,2WVALUATION $4,2(,aq LOT TRACT
JOB SITE APN
ADDRESS I
OWNER CONTRACTOR / DESIGNER / EN INEER
SC
52-195 AVMYRDA T A4, -600 YE A01 WE.
CA M53 lNTAO CA. 92;!x.1
(760)141r,"(59 CrRUrf 5978
USE OF PERMIT
PMt(X)F-CT AS;S A MA•F > IALS
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py'j�p �i pj� '�{{y SUMMA
b:JSTL .�8ikTi)e.•O�T•,9 OAT �IsLJ.i.CNbl iR�seY'Iw�e A.6•oLY
M d'.l�lw1n74LY�9 .mai F3�i!%',�7,iYi�AR 3
(This section need not be completed if the permit valuation is for $100.00 or less).RIM00FIrMH 101-000-418-000 U0.60
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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 ✓ p Zi
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
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
iLow Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
"gip' -29-2002 04:37P FROM:CASTO 7607728595 T0: 3479879 P:1
EmE aselfNel' 1119■
LtC#77om
j P (76b) 347.9869
PAU (76% 347-879
SAM ESTISLAW06 FP" (760) 34774120
634M PEACH ff2=7
ZINDm. C0. 9=1
HID 20: JOS:
MM SC017 CA3'['O ATTNJMODACMTO STK LE FAmmy HOME
5205 AYEIMA EZRREMA 52193 AVLNMA HERRiMA
LA QumTA CA. 922SB LA QUINTA ,CA
DEM '7737 PAR 764._ 7®'f2 m HIQAU L210.
ROOFER TO OBTAIN ALL OF THE NE4CESMY PERMITS AND INSPECTIONS REQUIRED BY
THE CnY OF LA QUINTA FOR A COAGILV T TEAR OFF AND RECOVER ROOFER TO TEAR
OFF AND DISPOSE OF ALL RWFM DEBRIS. ROGYM TO IAiSPECT PLYWOOD SUBSTRA'T'E
AND REPLACE ANY PLYWOOD MAT IS DAMAGED AT $30.00 PER SHEEF, AS DOUBCTED
BY THE CITY INSPECTOR. ROOFER TO SUPPLY AND INSTALL ONE LAYER OF 4 28 LB_
CH ASBASE NAILED ,7WO LAYERS OF 011 Eft GLA.SPLY HOT MOPPED BETWEEN LAYERS
AT 1 hWiAL 25 LBS. WT ASPHALT 1E. LAYER, UNDER A FLOOD COAT OF HOT
ASPHALT AND FMED, TRMIN AT 400 LBS. PER 100 SQ_ FT. OF # 318 COLORED GRAYEL,
ROOFER REUSE EXISTING ERHAUST VENTS. ROOTER TO INSTALL NEW 26 GAUGE
OR 'VFX,. STOP EDGE ME?AL AND ROOFER TO DISCONNECT AND IMCONNECT THE
=40 RVAC., CONDENSATION LINES ARL TO BE REDWA.LLED IN COfFFM AS PER
CITY CODES_ ROOFER TO REMOVE ALL ROOFING DEANdS AND LEAVE JOB STM IN A
BROOM CLEAN CONDMON. '
QPTI'RACI PRICE S 4,,t LO -0
TEW45; "% DUE UPON ST'ART, BALANCE DUE ON COMPLEIION
DATA O�
DATE 3-27.02
RODY04G INC. THi8 BTD 15 VALM FOR,__30 DAYS_
TniBi DNI34dm 3 BL86+L#£+09L yva 98:$X 9009/oz/SO