0312-096 (TT)LICENSED CONTRACTOR DECLARATION
1 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
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
64F,69)Pt
f I n1Im
.Date 1 I ' �' Signature of Contractor •1 '�` =! S%_ as 1� (v� yV ti
{,J
OWNER -BUILDER DECLARATION
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.
(?�' I 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:
Cartier 4 rjVr)? !7f fi�Il) Policy No. 046909 92692
(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,
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. �
gate`: I L OJ. Applicant t i e C_� a !t;� _ 'a 11, , :_:Z
r 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 purpgses.
� 4
Signature (Owner/Agent) - Date
BUILDING PERMIT
PERMIT#
DATE VALUATION i; -1. 'i LOT
IX31 ✓ W16 TRACT
y
JOB SITE
APN
ADDRESS 4641U7 D-11NE ]FLSiLN1.3 TROA3)
OWNER
CONTRACTOR / DESIGNER / ENGINEER
i1!fhi�7b. h! F:),.IT..1ViA,�i'
t'.,ti.>'^iirr'fi•: �:A�'C.�?T'1� +�5
42-335 W IV41- 7iKY'1'ON 0117,31
(7w)e00-4625 031L-0 2416
USE OF PERMIT
MISC, #Z i.AYMO1JS
TEMPOR-ARY CONSTRUCTION TRA11.9P, PERTUP -IJ 2403-430.
VAJ,UAVON
)1410.99 Zr
.I-1:�:�.t!dJ•J,1�Y�r.�� till.-t•��f1L9.At�5� E,
T R -M)', Ct XC' U('110N TRA -IL Z) ] £t1, Wt.} -425, t?ixU 1st0,UU
01M._!`O't'AI?:. MlT4i'1`MX 10M _ANM
,Mfialf M"TUX"}
k�ZOCi,41{i
eEllDEC
09 1003
REG INANCE DE i
BY
r
DATE FI AC
/ 6
INSPECT
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHA=AL 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
FOOLS a SPAS
BLOCKWALL APPROV S
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. 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
Gad Piping
Gas Test
Appliances
Final
COMMENTS:
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)
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THE CONTR
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CONSTRue-n
ED '2- HUMAN OCC
OCT.
MAY,
ci
" IWORK SHALI
AFTER .CLLrA
ENTIRE SITE
MA MUM CL
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(�� ! ull it 1 I
PADS SHALL
SPErVICATIc.
16. ALL. FILLS Sf
DENSITY AS
APPROVED 9
8 Ir ACCORDANCE
DETERMINED
17. ALL STREET II
AGGREGATE I
TO DE7ERMIN
STREET SECT
I& LOCATIONS 0
I II APPROVED Ti
VERTICAL PV
� TESTING 1N A
19- ALL UNDERGp
Garfications -
Block, Levet and Tie downs is based crntst uctlon sel,, in did using dry slack piers., $oil conditions are Nients responri6lilty. Does not
incwe local, state or personal properly tax. Does not inc ude'Elecirical hookupor piumbing,tie ins. All Mobile Mori leased equipment must
be. insurf d. Mobile Mini will provide insurance waiver for 10% of;" rental rate with 1.000 deft. ible on mobile offices..
Mobile Mini Inc
Brenda Cook
oocvmemr
AnTnuWas
afsrntp: MINI 2660'North Locust Mmue ■ Ria11o;.C'alifomia 92377 ■ 800-950-6464
Mobile Office Quotation
Date of Quotation: November 19, 2003
Billing :Ranger Enterprises Inc
PO Box 12966:
Project Location: LA QUINTA
Palm Desert, CA 92255
8X20
No SECURlTi' .
Billinu Period: Jy U MIX IX
Rent $ 145+TA
Restroom $ NO
Stairs each . $ FREEro4_r;
,ae►,ao:
T
6
One Tune Cha es
ace _
• i l :j
!
REFUNDABLE
Security Deposit $ 200 ;—
;'_•,-
Delivery $ 300
Block,Level,Tie $ 275
Tear-down $ 250
Return $ 300
Options
Standard Features
Handicap ramps
Security Bars
No Charge
Skirting
Mini Blinds
No Charge
Additional Blocks. Anchors & Tie-downs
Extra Large A/C -
No Charge
Exterior Security Screens
Steel Exterior Doors
No Charge
Door 8 Window Awnings
Exterior Power Outlet
No. Charge
Removable Hitch
No Charge
Ek J'Box - Phone & Data No Charge-
Hydraulic Door Closures
No Charge
Vandal Resistant Exterior Lights No Charge:
Fold Down Plan Table
No'Charge
8' Counter Top
No Charge
Overhead Shelf
No Charge
:Quality Construction
Standard
Garfications -
Block, Levet and Tie downs is based crntst uctlon sel,, in did using dry slack piers., $oil conditions are Nients responri6lilty. Does not
incwe local, state or personal properly tax. Does not inc ude'Elecirical hookupor piumbing,tie ins. All Mobile Mori leased equipment must
be. insurf d. Mobile Mini will provide insurance waiver for 10% of;" rental rate with 1.000 deft. ible on mobile offices..
Mobile Mini Inc
Brenda Cook
oocvmemr