0304-062 (BLCK)LICENSED CONTRACTOR DECLARATION
U) I hereby affirm under penalty of perjury that I am licensed under provisions of
F_ Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
(14 W Professionals Code, and my License is in full force and effect.
O =) ch License # Lic. Class Exp. Date
r` 7312160 H r, � %% 09/30/2(
r— Z Date �' �' Signature of Contractor -42'r
(D0rr
J U C) OWNER -BUILDER DECLARATION
W Wd 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).
C'')() I am exempt under Section B&P.C. for this reason
N Date Signature of Owner
ON
0)
FL Q WORKER'S COMPENSATION DECLARATION
CD I hereby affirm under penalty of perjury one of the following declarations:
Lo H O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W �= compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
M Q U ) I have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
d rn F— permit is issued. My workers' compensation insurance carrier & policy no. are:
v z CarrierSTATE 1�`IlND Policy No. 17054.54
ao �
r, C)
(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 with those provisions.
,.Date:. A__ . �' , Applicant i�
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
1 of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
C*
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 authorize .representatives of this City to enter upon
the above-mentioned property for inspection purposes. '
r,.Signature (Owner/Agent) �r � � — Date bj-i' A�/1.�
• 1 -:BUILDING PERMIT PERMIT#
-���'
DATE VALUATION LOT TR CT
Q74/07tW $3,2t�+ .00 .
JOB SITE
ADDRESS -M AYNNIDA 10, R':.,ZERAI
APN
_
OWNER
CONTRACTOR /DESIGNER/ EN INEER
R01:i,DBZG HORIZONS
PL)i D190 HORIZONS,
-U-600 COOK ST. On. 120
42.600 COOK ST, 0) 20
PALM r'iBM. T CA 92211
PAI MDUS.ERT Cdr 92211
(760)340-474,8 C,B114 "56
USE OF PERMIT
100 LF 6' &.44 LF. -i' SLOC .K 'WAL1. , L71LCO SYSTEM
6 FT. WALL 100,00 LF
4 FT. WALL 44.00 LP'
,�4,fj AjVD I3 COSI" 0)F 4:0XIS'l J,?' ?CiT0X
3,W4.90
PIMWIT1' FRE SUMMARY
CONSTRUCTION IEEE 101-000-418-000 Sb:S.00
O
APR 07 2003
CITY OF LA QUINTA
FINANCE DEPT.
s riT -TOTAT C ONSTR.irL`'T ON AND PLL C'TMX'
L%.S�'�1��2'AyU 13�
SO.iTO
a :
�
`IY)TAL Pffma:l' FUS DUE NIDW
S63100
RECEIPT
DATE
BY
DATE KNAL
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
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
, p `t'
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
• Final
O
Gas Piping
PLUMBING '/APt2ROVALS
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
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
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