0306-177 (RPL)LICENSED CONTRACTOR DECLARATION
U5 1 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
c*4 W Professionals Code, and my License is in full Xce and effect. „
O =) ch License # ••Lic. Class Exp. Date
f
Z r— Date �c' t Signature of ContractCD
or = ^'•- t + y� �� '"�r
J U C) OWNER -BUILDER DECL'ARATIO�
LU LLI I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ t1 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).
cr) () I am exempt under Section , B&P.C. for this reason
N Date Signature of Owner
ON
rn
d Q WORKER'S COMPENSATION DECLARATION
o IM I hereby affirm under penalty of perjury one of the following declarations:
Lo FZ 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.
m Q () ( ) 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
Il rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
1�t Z Carrier ICX..10T Policy No.
cb Z)
r -a
J (This section need not be completed if the permit valuation is for $100.00 or less).
(q)' 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
3 Code, I shall forthwith comply with those provisions ' f
Date: t > Applicant
Warning: Failure to secure WorkersTXompensation 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/Agent) 'A" t'v' 4` L!' Dated 1
PERMIT#
BUILDING PERMIT -
~
�
DATE TRACT
ji C' VALUATION �� �rtiV'F•<�� LOT
f r t
JOB SITE ADDRESS lr_�_ TNS .DX44f1w ' I O rW ISTrar ;
APN
OWNER
CONTRACTOR/DESIGNER/EN (NEER
is WRY Y C.?R0
NICO Al I„i: iAd PO'A
1 Si --655 IM r'? oii.,iAt7J' aS"1 F i'
82-162 CFAX.,_`KiWN AVE
J..&1,171NTA CA
WD10 CA 9%1:1.01
USE OF PERMIT
01011,, A' ir)1R F%'A
°(,)tle,ii6'dL .Via.li6L lCt/�I�l a ,ittsUL, :'.:!1(! B+N.S '•.rll N 1.•'1.?":r.A5K
1"i<!SFF.C`Yi. I!I! V&,.HPM 1T .A'AiC:)'X)t UF_9NP,' T f.WC:C.•3IPM
'4''ALUA11014 17,30110 LS
1�:tYxkmv C1CJST ir.V 1`1,a?� II.RucrfT�"�.'�f�
T' 1114U00SXa
''��]] nnYY����7`ee qq (wry �,`'.�A ,�'7l
PWC:1 Y RE R3V1TMLr/�i.LC.li -
MMI, I, C1111ECK FEE
Cti' iSTR UC TION W'L x:11-GGC3 t'� €�•41(3�J :t i�.;7t3
W&C1iAWCA 1.1 VU -- POCIl
ELiPMTRICA , FEE .„ nGOL 1-OCID-420-000 $45.00
PIAI1AhBINO FEE POOL $27,00
i
UVID—TOTAL. Ct1WMIzliG°'i'1+r`w P kw A.AAS' (M-7—cill.
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D
D T. KIM Tr x:913 81171 INOW
JUN 16 2003
CITY OF LA QUINTA
FINANCE DEPT.' I
RECEIPT +
DATE<� / i
E'r �4�'a j
By �- E F D
��."""r-
I SPECTOR
l
0
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
OX to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wali Insulation
Condensate Lines
Pa 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
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
Smoke Detectors
Temp. Use of Power
Filial
Utility Notice (Perm)
COMMENTS:
�- 65�5 A CITY OF LA QUINTA SF -CONTRACTOR LIST
JOB ADDRESS 2555 /,/A0t-PERPA1T NUMBER �� 'p�1IN R� ILDER
This form shall be posted on the job with the Building Inspection Card at all times in a conspicuous place. Only persons appearing on t Is list or their employees are authorized.to work
on this job. Any changes to this list must be approved by the Building Division prior to commencement of work. Failure to comply will result in a stoppage of work and/or the voidance
of building permit. For each applicable trade, all information requested below must be completed by applicant. "On File" is not an acceptable response.
Trade/ Classification
Contractor
State Contractor's License
Workers Compensation Insurance
City Business License
Company Name
Classification
(e.g. A, B, C-8)
License Number
(xxxxxx)
Exp. Date
(xx/xx/xx)
Carrier Name
(e.g. State Fund, CalComp)
Policy Number
(Format Varies)
Exp. Date
(xx/xx/xx)
License Number
(xxxx)
Exp. Date
(xx/xx/xx)
EARTHWORK (C-12)
CONCRETE (C -8)G:
.-.
L� C� `
$`s�•��L;,
0-3.
p
FRAMING (C-5)
STRUCT. STEEL (C-51)
MASONRY (C-29)
S e.
/4i'i S�i
So3ljj
3/ D
PLUMBING, (C-36)
M Cc n" 1 yr
sQ
y
S 3
-.rll
LATH, PLASTER (C-35)
\eJt
0 0
1 31�
I r
DRYWALL (C-9)
HVAC (C-20)
ELECTRICAL (C-10)
r�"�C
i
ROOFING (C-39)
SHEET METAL (C-43)
FLOORING (C-15)
GLAZING (C-17)
INSULATION (C-2)
SEWAGE DISP. (C-42)
PAINTING (C-33)
CERAMIC TILE (C-54)
CABINETS (C-6)
FENCING (C-13)
LANDSCAPING (C-27)
POOL (C-53)
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