0108-212 (TT)U)
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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 8 (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 /
'li2.4 A.D
Date '' Signature of Contractor
_.._ __..,, __..._._....,•OWNER -BUILDER DE
I 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 employee with wages as their sole
compensation, will do the work, and the structurgx 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:
Carrier Policy No.
A1+i1F,sF1r".t:9H CASUAL We., 133201131
(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 mannergo as to becorrsubject to the
workers' compensation laws of California arid)J' agree that if I'lshoul become
subject to the workers' compen�ft�hjbbs�
iorovisiorls of Section g�700 ofh h r
Code, I sti ll fotthwith comply wprovislions.
IS
Date: Pr 7 it r 7 ADDlicant r I'
WeminV.Ft�lure-to-secure-Wdf'k -Compensation coverme is unlawful and
shall subject an employer to criminal' enalties 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 !ff bes. -
IMPORTANT Application is hereby Aadeffto the Director of Building and Safety
for a permit subject to the conditior}s and restrictions set forth on •his,
application. of -
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 subjeet permit to cancellation.
I certify that I have read this application d state that the above information is
correct. I agree to comply with all City, d State laws relating to the building
construction, and hereby a orize repr sentativesof t Is City to enter upon,
the above mentioned propIrylor ns ie ion purpgszes „;• ) is
Signature (Owner/Agent)
BUILDING PERMIT
DATE VALUATION LOT Yj�>.-;�g,�i, TRACT
JOB SITE APN
ADDRESS
48-803 1 /2..3.t",JI,5KN1KA VM_ _ fD ld'VE -
.OWNER CONTRACTOR / DESIGNER / ENGINEER
I,1';:i+1s-YA C'Ci�vi Ia'T(iA131i+1 Zaf iN�1 ? �*r,!1�4iui tl2 i'I'k:E
74ROD (11MOANTA MkIV:l'rifMO V1600 CHRAIANIr.€'A.D;RIVE #200
loll iITt;.A4 VMTC) CA 92691 i'VI[b .10 V11,30 CA 92691
Gg�1�1ti3��S:5(}{4 C.E3C:f!
USE OF PERMIT
" NPffl�0PAElY CC7NS7R;ICT101f TRAJ14eA PER. MUP 02001.305
V A1..1:7.r`411014
500, ttp 1-4
F1,711MA'MI) CCIST 0F COINUMi:d(7flon `Si1t),V9)
I':lytrd'AO's`ff 9i'I.'7s; Wp.Ahullzy
TMP WMEM3,E.1CTIO)4 i RAJ1. FJ 1 01 -000-42,33-000 $200,00
AUG 21 2001 T(VIAL PERNITY 111TIVIN.DI;IENOW i ,xxb
CITY OF LA QUINTA
FINANCE DEPT.
RECEIPT DATE } BY DIEFI D O INSPECT
NSF CMN RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BULMNG APPROVALS
HECHAMCAL 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
SLOCKWA1LL APPROVALS
POOLS _ SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
[i LUMMMG 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
URS_iy Notice (Gas)
ELECT MCAL APPROVALS
TeTnp. 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: