0308-245 (SFD).j t" 1 4
LICENSED�GONTRACTOR 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
04 W Professicn'als Code, and my License is in full force and effect.
C) License # Lic. Class Exp. Date
LO
UJ
+ 3 iTC < M0/04
o Z r` Date Signature of Contractor
CD 0- �• '�
J U C:) OWNER -BUILDER DECLARATION
LU W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ a License Law for the following reason:
N
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).
( ) 1, 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
LO
N Date Signature of Owner -
ON
CL Q WORKER'S COMPENSATION DECLARATION
O 2 Z I hereby affirm, under penalty of perjury one of the followir g declarations:
Lo O O 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 0f'the work for which this permit is issued.
CIO Q (� (j) I have and will maintain workers' compensation insurance, as required by
dQ Sebtion 3700 of the Labor Code, for the performance of the work for which this
LIDpermit is issued. My workers' compensation insurance carrier & policy no. are:
? Z Carver< H_ Policy No.
w Z) • OLD RET'C�1 UC.' INDU MWC100345400
C)
(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 f rthwith comply with,tl'ose provisions:
Date:' �a Applicant-✓C��(�,
Warning: Failure to secure Workers' Compensation coverage is unlawful and -
shall subject an employer,to criminal penalties and civil fines up to $100,000, in
addition•to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose.request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify.,
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within .180 days from date of issuance of such
permit, oe'cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
• correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property inspectiiotn' purposes.
r-.1- �gnature (Owner/Agent) }`��J Date
BUILDING PERMIT PERMIT# /
,V/
DATE VALUATION LOT TRACT
. 1 ISA,725.` 0' 5 305 l-1
JOB SITE
ADDRESS 44-055 WA CATAI .STA
APN
604-4F3:2-009
OWNER
CONTRACTOR/DESIGNER/ENGINEER
LF"M FIC3IviM OFCALTORNIA
LE1014 � FIOWS OF CADORR'LA
7B-401 C7 I.-MG11WAY l 71
78-403 C HIGHWAY 3 31
Lt*i QUJNTA CA 912M
I.& Q7J, %1TA. Chi 02233
(760)777-0131 CGLO. 3434
I
USE OF PERMIT
Sk'O = LO'1 �, PLAN W.: PERMIT [.7OF-S NOT INCLUD9 FILOICK W- AL S,
POO.1, ZPA' 0%9kJ?iAP$kCtk16 °ra fiEDl(l"0N TO FLAN CHW
a�g{Vi3I9LeIsSU.".��E Op? SAME PIAN TYPE
lift DUZS6
TRAC f.CONSTRUCTION SF
E'Oi�.C3iJl�fa'Tlis $58,00 SF
QARAsIFIC; kRPORT. .462,00 Sr
P
.
ES11M 7.1110 COM, 011 CONS$'.l UMI '014
155,75.10
C-0148.PRUCTI.JN FVF. 101-000.418.000
.P,L.P.N CH1r X FERE $!71.x"!
1dECf S1CA.,LFEE $60.00
ELECT TU f7 t, 301 O(10 -42d3 -(FCO $13:3.Mi
PlAWTHO FEIR 101'-000.419w001 $1t 125
S'TROA1CtMOTION CLOT;•,RF-.SSD 101-000-711-000 $15.47
GF.Ai3WO FeE 1.01.000.423.000 $150
DEVELOPER ER IMPAC:'T FEB, $�,QU9.tit1
psi i �'>tiC3.i ►►L t�CSk g 'Pc'IJ{.`,'. fGA�i Ah>S5 ,f Cdr ICK
L PLRUIT PX—AS DUN NOW
DEC 15 2123
CITY OF LA C31ntr-37A
�R�ECEIP �'
y
I D E FI D
SPECTOR
/
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVA S
MECHANICAL APPROVALS
Set Backs _
Forms & Footings
Underground Ducts
Ducts
Slab Grade
Return Air
Combustion Air
Exhaust Fans
/
_
Steel
Roof Deck .,
_
O.K to Wrap _
Framing _
Insulation
F.A.U.
or _
Compressor
Vents
j RAN
1
Fireplace P.L.
Grills
—W
10y
�
Fireplace T.O.
Fans & Controls
/
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final i _
POOLS - SPA
BLOCKWALL A PRO ALS
steel
Set Backs i
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 i
Appliances.
. ..
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL AP ROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final i
Utility Notice (Perm)
03/17/04 17:05 CDFARIFACOSTAMESA 7607777011 NO.?90 D01
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