0307-348 (BLCK)LICENSED CONTRACTOR DECLARATION
U) I hereby affirm under penalty of perjury that I am licensed under provisions of
I— Chapter 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 C) License # Lic. Class Exp. Date
r �w r- 430121 13 C20 C36 M uQ/gl� lu
Z � Date Signature of Contractor
O
(o.
J U (� OWNER -BUILDER DECLARATION
HWW r` I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) 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).
U) () I am exempt under Section , B&P.C. for this reason '
N Date r-' Signature of Owner
0 CV
O)
d Q WORKER'S COMPENSATION DECLARATION
j Ir I hereby affirm under penalty of perjury one of the following declarations:
2 0 ( ) I have and will maintain a certificate of consent to self -insure for workers'
< W �= compensation, as provided for by Section 3700 of the Labor Code, for the
J Q performance of the work for which this permit is issued.
D Q U ( ) I have and will maintain workers' compensation insurance, as required by
U Q Section 3700 of the Labor Code, for the performance of the work for which this
L 0 Z permit is issued. My workers' compensation insurance carrier & policy no. -are:
CarrierS,�ATE aD Policy No. Xf�1A�b9.0:�
co D
� f3
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
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date:— Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in'Section 3706
- of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit, subject to the conditions and restrictions set forth on his
application. `
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
• correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) Date
BUILDING PERMIT PERMIT# Gam/$
'
DATE VALUATION LOT' ""' " TRACT
07ra3rd.00 $4,332:: z 1311K 207
JOB SITE
ADDRESS 4,..+2—&55 FISJMHOWM 1iRrtfF,'
APN
_
OWNER
CONTRACTOR / DESIGNER / EN (NEER
DG14 1yEVLL01.c f Jr CORP
DGH DRV,7,0PW,_Rt, CORP
7 R-921 ' TRA:WAY BAY
78-921 RIWA' Y BAY
BTi"RMYJDAMTESS C.A. 92261
BE.,'RMUDADUIM CA 92261
t
(760,360.8706 GTL#k 1526
USE OF PERMIT '
GEMMAL B T&DI90
,50 IX 6' Q%Ri)FN-WA3LL. RXAR P&20 .(:P r' ViTALL A140 301..F COMBO
11-19°itETAM1NO WITH 6' OARDYN WA14, PER. CfTY STANDARD ALONG,.
SOUTH KL.
61l. WALL 130.00 LF
SFT. WALZ 50.00 L
..
XM.7:Edi'at1,i'.i�'.1A 0D.S11 alT G1;;►'w3T1':t7C73ON
x 4,=.50
CONSTRUCTION FE .101.0017-413-000
JUL 2 8 2003
CITV OF LA QUINTA
FINANCE. DEPT.
,9XYB-T rAL CCi),TLT,-_ r 0k AM VLAW CRFECK
$1121.00
LESS M-PAWIWO
$0,04
h's' ME NOWS72.00
RECEIPT
DATE� /
BY _� y
0A7 JIN
INS4�
f �
i
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
O.K. to Wrap F.A.U.
Framing Compressor
Insulation Vents
Fireplace P.L. Grills
Fireplace T.O. Fans 8 Controls
Party Wall Insulation Condensate Lines
Party Wall Firewall
t
Exterior Lath
Drywall - Int. Lath
i
S
l
I
Final
) R
Final
POOLS-SPAS
BLOCKWALL APPROVALS
Steel
Set Backs Electric Bond
Footings Main Drain
Bond Beam Q 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
COMMENTS:-
T
Final :..
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures.
:Main Service
1-
Sub Panels
Exterior Receptacles
: G. F.1.
Smoke Detectors
Temp. Use of Power
i
J
Final
Utility Notice (Perm)
�t