0307-283 (PAT)LICENSED CONTRACTOR DECLARATION
I hereby 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 effect.
License # Lic. Class Exp. Date
&6125 B RIC,
0 0121C
Date Signature of Contractor -�
OWNER -BUILDER DECLARATION
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 employe s -with wages as their sole
compensation, will do the-work�anc the struptufe not intended or offered for
sale (Sec. 7044, Business &,Profession##Code).
( ) I, as owner of� the property, am exclusively contracting. with licensed
contractors to construct_thefproject (Sec. 7044, Business & I Professionals
Code).
() I am exempt under Section �� B&P.C. for this reason)
Date 'Signatur, hof Ow e`r
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 Laboh 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 STATE FUNI) Policy No. 044.010019860
(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.
Dated Applicant
Warning •Failure to secure Workers Co pen sa t o '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 madeto the Director of B Ilding and Safety
for a permit subject to they condition's and restrictions Yset forth on his
application.
1. Each person upon whose'l5eha-1fAthis application is made'& each person at
whose request and for whose benefii work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, t&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..
Sign" ature (Owner/Agent) ! Date
BUILDING PERMIT - , PERMIT#
DATE 07/21*VALUATION sl�M.70 LOT TRACT
JOB SITE
ADDRESS 49-33 'IA C I NQUIS'`�i`.f DOR
APN
,
OWNER
CONTRACTOR / DESIGNER / EN (NEER
MIM RAW
1C:CIRTZ COKM..1ZUCT 0W
49.343 V.,,A CONQUMADOR
74.442 PAR.OS=.A
LAQUT14TA. CA 92253
PALMDESERT CA 92260
V60a346-6932 Com` 4547
USE OF PERMIT
PAnO
79 SY LA;' T11CZPATI Ar.Z1Z PF. -R CITY S i A RO.
i
FC?1ZOHMATIO ) 74,00 3i±
l
J
X.VnNATED COST 0r,1dQ1vIMU1_-n0,N
ERIVII[T F`EE SIAZ L'RY
PLAN CHECK FP,
CONSTRUCTION FEE 101-000-4418-000 $2700
STRONG MOTION ROM-WID 101-000w241-000 $130
s �.�--
_
SM -TG AL CONTCRUCTION AWD PLAN CMCK
$45.05
LE 33 PRE -PAID FM9
Q
$0.00
D• �
AT, PERMYT r, EES ]YOE NOW
S4N.05
JUL 2--12003
CITY OF LA QUINTA
FINANCE DEPT'
RECEIPT
DATE ,Jr f
BY
DATE FINALED` ��
INSPECTO
2
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING. APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 6 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
5
Final
Final V5, " —
BLOCKWALL APPROVALS
steel
POOLS - SPAS
7, 2
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
' Final4g�z LIZ .
Utility Notice (Gas) V611, J
- ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbctuures
Main Service
Sub Panels
Exterior Receptacles ;.
G.F.I.
Smoke Detectors
Temp. Use of Power 01
Final
Wiry Notice (Perm)
COMMENTS: