0401-310 (BLCK)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Fes- Chdpter 9,(commencing with Section 7000) of Division 3 of the Business and
N W Professionals Code, and my License is in full force and effect.
O =) M License k Lic. Class Exp. Date
CY
B 6/30/05
Z r- Date S49nature of Contracto —
�Q1, / a
r` H� OWNER -BUILDER DECLARATION
Ha rl- I hereby affirm under penalty of perjury that I am exempt from the Contractor's
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).
( ) 1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
C'0 () I am exempt under Section , B&P.C. for this reason
LO
C\I Date Signature of Owner
ON
rn
Q WORKER'S COMPENSATION DECLARATION
pQ (r I hereby affirm under penalty of perjury one of the following declarations:
r F-; O () 1 have and will maintain a certificate of consent to self -insure for workers'
X w LL 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.
C0 Q f) (/) I have and will maintain workers' compensation insurance, as required by
O Q Section 3700 of the Labor Code, for the performance of the work for which this
Il rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
t Z Cartier Policy No.
ob RATIC)NAb UNIUN ?I65833
�O
J (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 agFee that if I should become
1 subject to th!e workers' compensationYprouisi,onst6f Section 3700 of the Labor
e�•i� Code,,l shall forthwith comply with arose p10o ilslor�S.,,�,,.,,,,,,,,,,�
Date {�� ApplicantR.-.
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 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.
f Signature (Owner/A ent) Dates ,t
i
BUILDING PERMIT PERMIT# //
DATE VALUATION LOT 0401-310 /TRACT
J . / . i,aZv clv 46 / 30023
JOB SITE
ADDRESS gl • � DESEW VYLLr.LOW ORM
APN/!
f
OWNER
CONTRACTOR/DESIGNER/EN (NEER
SI3�;1> t.AC,�U3t3TALI�C
S_ FALAC,ZITNTA.UC"
81260 AVEtM 62
81260 AMMM 62
LAQUINTA CA 42253
LAQUMA C.A. 42213
('7603777.6(05 Mui TSD
USE OF PERMIT
GENEM.13ULDING
.0 I -F. 6' 81XtC.X 'WA.L% ORCO SYSTEM
0 i' f, WALL 65.00 LF
ESMAI COFK OF f :{3N5'1Rilt TION
1, s*.I �
PERM(T YM KTAMOAA 2Y
C009MCTION IMP 301.000-418.000 13Q,130
PDD
L ._ !
FINAI1'C2_ GF l
S[Jis=1.`CYi AL CONS Kl.lCrION X141)PIAN N CIMCK
$39.00
U53 PRE-PAED FEE
50100
TOTAL 1'1:I IN UT FEES ]3UR NOW
ssq,o0
RECEIPT
DATE
BY
I DATE IN E
INSPECT9ff
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 8 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
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings i
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final '
Gas Piping
PLUMBING[ A ROVALS
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
COMMENTS:
-
;
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)