0308-248 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
I— Chapte jr` (commencing with Section 7000) of Division 3 of the Business and
04 W Professionals Code, and my License is in full force and effect. /
O =) co License # Lic. Class Exp. Date
r- du7
LU
9830/04
jr�
Z r Date' f�,/Z %` Signature of Contractor L%f•.r%� �r`�
rU p ~ OWNER -BUILDER DECLARATION
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ a License Law for the following reason: -
U) .
Z_ ( ) I, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure isnot 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
O I am exempt underSection 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 rinsurance, 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 OLP P..,T,T�t s tic Di ) Policy No. hr°o' 10d !✓4fiD.
(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/fs1>those provisions: `
Date: TJ, /`- e `-1 Applicant '.�PIle
/
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.
r �
Signature (Owner/Agent)�i9.6' Date %��":`
BUILDING PERMIT PERMIT#
DATE I VALUATION LOT TRACT I..
JOB SITE'
APN
ADDRESS 44-01 ys A loCk.Zed VLXbi.c i�+�-•'�
�.2^
OWNER
CONTRACTOR / DESIGNER / EN INEER
UWAR MIKE S OF C;AMr (3RNIA.
)MNUAck 1101-W OF CAV Math.
?Q -4s0) Cs FUCE? WA.Y 1')1
'18.401 C HIGHWAY )1)
t.& puww-, CA 9 2 25:1
LA Ql31rA7`1' CA, 922 3
(766)7' 11-0131 CBL# 3434
USE OF PERMIT
MOLE FAMI'LY DWE'L :£L G
,SSI) , LOT k i1.iVN 44 P�.14i i DOES I"'I'3''d rNGVJ0Y, .W OCJC VVYALLSy �
POOL, SW A. OR 15RfV LW_4Y A'PROA.CH
MALT C0143TRUC TION 3,?60.00 S
PORE;l.OPA"flf:t 17-3,00 Ja" ,
Can 01? Ct,�a?��r`MUCTIOn
161, 0.90
� ';♦ g/y{ •�;. �(y,�. q p,g ySq-yST_TNA:I�':�
1i YM11Fw•S:P.1.�, A1sIM R�7.lVAAIAR.Y . ..
CONOT)"`13C ION RZ 101-000-418-000 $250,50
PLAN CH`CC K F rit 101-000-439-318 031.05,
tJtF cavicA.1, nx, 101.000.421.000 360,00
LI.P:x'T ICA 'ate. 101 *•000-420-000 $139.60
PLUtt.+t'MO F2110 101.0110-41.9-000 $160,00
S.'ROUG MOTION FUS - RESID 1,01-,041-000 X153. t€➢
0` 2000-423.000
GRADYNO ME 101.t
D'friiX:;.,S PRP IMPA= ",If 40 .00
" ' + S•ETWTOT;A. GANDP—L 3 C r, CRC.
i '33 PRE -PAIDFRE.,
X0.00
� AA O�1',. 'Is'.it�.tit1�!I1'is FEE, 6s IME NOW
ar ,3511- 53
15 "cQ3
�. 12.
RECEIPT .._.
A ° °°' °
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
_
Forms & Footings /i ��
Ducts
_ _
Stab Grade ,r�
Return Air
pL�
_
Steel
Combustion Air
_
Roof Deck , ,
Exhaust Fans
_
O.K. to Wrap ol
F.A.U.
Framing �� _
Compressor
Insulation —i
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
POOLS - SPAS
BLOCKWALL APPROVALS
Steel.
:Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING ApP V S
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
En ppsulation
Gas Piping
Gas Test Y
Appliances
Final
COMMENTS:
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)
03/16/04
17:22 CDFARIFACOSTAMESA 7607777011 NO.782 003
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