0311-246 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
H.Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
C14 W Professionals Code, and my License is in full force and effect.
C) License # Lic. Class Exp. Date
LO
- r- 799746 13 MCIt-
Z Da a Signature of Contractor ,�,�.-•-_ ,/
J U OWNER -BUILDER DECLARATION
W WW r` 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).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
C0 () I am exempt under Section , B&P.C. for this reason
LID
N Date'- Signature of Owner
ON
Gn
d Q WORKER'S COMPENSATION DECLARATION
C) Z I hereby affirm under penalty of perjury one of the following declarations:
p () 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 L) (rj I have and will maintain workers' compensation insurance, as required by
OQ Section 3700 of the Labor Code, for the performance of the work for which this
LO d 0 Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
O 1. IO 302.4367
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 agree that if I should become
3 subject to the workers' compensation provisions of Section 3770of the Labor
Code; I shall orthwith comply with those prov sio..s"
-'Date: J• Applicant �T �''__
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 Ouinta, 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 inspectio , purp�Ns,,
�,.. Date��F < ,/��
Signature (Owner/Agent)"",,. P
& BUILDING PERMIT PERMIT#
DATE VALUATION LOT 0311.246 TRACT
$1..3,(a. 0.00
JOB SITE
APN
ADDRESS 5
2^-4rv-z .E MET? Man
I
OWNER
CONTRACTOR / DESIGNER / ENGINEER
MT LAWMI OSI*:
A.`fL"TA.3 nSyVE '3'AAI : y GROUP
51-105 AVEN.il A V1MA H-261
51-105 laVi�T DA V.9—TA 0202
LAQUDITA Cts. 921AW
.1.AQ`ilWITA f2A 92253
(760; 711.-102.3 CRU 030
USE OF PERMIT
P0OL ARD/ R, SPA
P0� LJSP.E3..Ai.h.RA,1 I BAIR '.;i:RS SHALL RZ IN PLACE AT PR&k''LASTLR
INSP&:'HON, P,0MV54T ENCLOSURE NOT i2dCLWDI D
•
'V'11l:ksATION 13,000.00 LS,
HST".'.I,°E13 C0Y1' 0I.r f.ONSMUMON
?3,GIiDt2t3i3
P112 VJTr F112 £3EJMMARY
I'I.AN C`TMI; FEEL IOI t10C�•�339 3I� $93.60
COIF MUCTION FEE 101:-000-418-000 $144.0
MECJ4AN1C9.Al.dFEtA • PC,10L 101-000.421-000 $24,00
F.1..='RICAL PIE — P001, 101-000-420-000 $43.00
PLtdMBI?SCI FBR -- POOL 101-000-419-000 $27.00
SKM-1- T.AL-.CONS'.fR.UCTION'AAW.)PLM-11CIMCK
13314.60
U..".0 :P'R.&PAID FEES
$0100
T OTA -L M& -11 KE rAW Now
$333.60
DEC 0 4 2003
CITY OF LA QUINTA
/ Y- BY DA FIN ED ,,-- INSPECTOR_
.` 6 R
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
BLOCMALL APPROVALS
Steel
POOLS - SPAS
Set Backs
Electric Bond
d
Footings
Main Drain
pe
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
X 11
Underground Plbg. Test
'
Final
Gas Piping
P
PLUMBING APPROVALS
Gas TA10
Electric Final
I .
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:
J_
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71:`i
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