0302-197 (BLCK)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`df`the`Business and
04 W Professionals Code, and my License is in fullaforc'e and effect.%
C'� License # /. Lic' lass ".Exp. Date
J.itc V2.8105
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act Signature Z
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J U OWNER -BUILDER DECLARATION
Hd I hereby affirm under penalty of perjury that I am exempt from the Contractor's
to 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).
co () I am exempt under Section B&P.C. for this reason
LO
O N Date Signature of Owner
01
a 'Z WORKER'S COMPENSATION DECLARATION
C:) Z I hereby affirm under penalty of perjury one of the following declarations:
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O () I 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 _ Q performance of the work for which this permit is issued.
m Q C) ( ) I have and will maintain workers' compensation insurance, as required by
p U Q Section 3700 of the Labor Code, for the performance of the work for which this
Il I. permit is issued. My workers' compensation insurance carrier & policy no. are:
Z Carrier STATE MID Policy No. 430119
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(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 Boas to become subject to the
workers' compensation laws of�California, nd,2dgree that if I should become
3 subject to the workers' compensation pr�o�visions of Section 3700 of the Labor
,Code, I shall forthwith comply witho=e, provision S.
Date: 6ppliccant.-�"'---'"��----
�� 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 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'thls application and state that the above information is
• correct. I agree toycomply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned pro r -inspect' h purposes.
Signature (Owner/Agent)/' .-•�.'/ �. -• '.�Date
BUILDING PERMIT PERMIT#
DATEVALUATION By 6YeCgT LOT TRACT
ADDRESS .�.:�•���.bD,AVXNW/F�. K►+ rF_R_RA JOB SITE
APN
OWNER
CONTRACTOR/DESIGNER/EN (NEER
s Ae'r MCK
IMWARM GEORCIE VASA
i..�.a�tl.`I+avTA GAS, -922553
Q60)77:-3180 f,TUR X85,
USE OF PERMIT
Iii L)r V �.Lt MKI fVtd,EKIM, CITY 5'TANT3�1F1XV2 5' Ot,.7JAAYfSNTA.L:
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6 FT. WA,.L?u LF
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kftw r];: f: SrUMARY
0014ST RUCTIO:R3 FEE 101 -000.41 8.000 �f�3,13G
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MM' AX, OONOTRUCTTO-K. AMD PIJ+WCE•7Etw;K
$63.00
FEB 2 5 2003 I�
CITY OF LA QUINTA
FINANCE DEPT.
RECEIPT
DATE / .
BY r
DLT FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
I 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 Wail Firewall
,
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Footings
Electric Bond
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
_ --7
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
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
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CITY OF LA'QUINTA-
BUILDING A SAFETY DEPT.
APPROVED
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