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LICENSED CONTRACTOR DECLARATION
I;iiereby 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 elle t.
License # Lic. Class xp. Date
7190,1
Date Signature of Contract
�. OWNER -BUILDER DECL' RATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
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:
Carrier Policy No.
(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, n agree that if I s ul become
subject to the workers' compensation pr ��'�ns 'IfSection 37 the Labor
Code, I stiall forthwith comply with tho dbvis' • s. OF
.Date .0-10!-41 1Applicant w D
4.-.
`Warning: Failure to secure,, o er�ompens on coverage is unlawful a
shall subject an employer to criminaYpenalties and civil fines up to $100,000, i
addition to the cost of compensation, damages as provided for in Section 370
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safet
for a permit subject to the conditions and restrictions set forth on hi
application.
1. Each person upon whose behalf this application is made & each person a
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 aFtvto
information is
correct.'I agree to comply with all City apd S to laws rectto the bLilding
construction, and hereby authorize W se atives of Is enter upon
the above-mentioned property for s _cti purse . n
,Signature (Owner/Agent) Date {"` M 1W
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
73 7883& 1
JOB SITE
ADDRESS 81410 LE039NDS WAY
rAPN
Xt-5004M
OWNER
CONTRACTOR/DESIGNER/ENGINEER
3 C0R1'0RA 1 .AS 4 r
23" CORPORATE Y=';4,.A7.A 9-245
M'fi`k,F3' paRTISEA011 CA. 92660
NEWPORT BE,4MA 'CA 92,660
(94M19-49115 C 11 5337
USE OF PERMIT •'A
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;�.
90TYMATM) COST OF (_'0M!dJC,T10A
XTRUtT 7'M SUMMARY
PLAN Ci3t3.t 9 RX, s 101,i000439.318 ffi�;fl; f A
S;t9'e� "EF tJC 'fli:3�I P � 103-000.4'19-Wii Vu,. 13
GTRON(4 MOTION 1+'EF • ii.ESID 101-000-241-000 9,54
JUN 1 9 2001
CITY OF LA OUINTA
FINANCEDtEgqPT
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j��7i'S-1Ct.J AL C';10AYhY'dRUC11MY A�WL'�LZdi:f C.dMS+K
$99.60 •'4
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$99.60
LESS PRE -PAID MILES
+'1'01AL PZ i°�A' T 10PON DI'g LV'(W
43
RECEIPT
DATER \V�
'10
BYE
DAT N L
INSP T R
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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 & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
/ _
Final `�"`—�`f _
BLOCKWALL APPROVALS
Final
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
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
APR. 18 23 (THL) 12:1.6 LARRY JR 9096052798 PALE!. 2
Lo
iaYB ■4EMG.
INC
April ls, 2003
LWINC
541 KET' spi N6 Dit.IV'B
ONTARIO, CA 91761
RE: MuiM" MMS MRTWICATJON
DEUR SIltS:`
PRS. GLASS WM
SY5TEMS UX. CERTS.TKAT 'iX•3E't`Ei iPERMGLASS
PRODUCTS, MAT WE'ARE• SLJPPT:ING'To YOU QN YOUR INVOIW3�-1 �,
YOUR. PUPCHASR ORDMW 711083 MM OR EXCEA M MtYIRFi.1<dENTS
OF THE FOJLLOWmo SPECMCAT16NS AND TESTS:
.1) ASSTM C.103"S STANDARD sPZMCATION.FOR VIAT GLASS
2) ASTM C '1046-m S'TA"An SPECWCAVON FOR EZATED
TRZAItUnATMASS
3) ANQ 20144 FOR SAFM, GLAZV4G MATENIUS
4) • t6 ark- 0i C n dww B"ZTS STAND" D FOR
ARCIMrrZCTURAL GL&MG MA ALU
IF YOU'SHbMID HAVEANY QiJ nON6.•ORPiQuam Otlam'
:24FORMATIOX PI&ASE DO NOT NATE TO CONTACT Us.
�IAMEROS-
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