0301-067 (SFD)1 � (LICENSED CONTRACTOR bECLARATION y
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 # y Lic. Class Exp. Date
054074 B inc 7131/03
Date '{ %f `- Signature of Contractor •f f),I
OWNER -BUILDER DECLARATION 1
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 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
Codej-
() 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:
1 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 37,OO'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.:. ��7 : 11 1t). Policy No.
(This sectlon',need not be completed if the permit valuation is for $100.00 or less).
O (.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`dgree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code; I sh'all forthwith comply with those provisions.
Date: Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer'to criminal penalties and civil fines up to 1100,000, 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 buildigg'
construction, and hereby authorize representatives of this City to enter.:upoW
the above-mentioned property for inspection pu pose's. }/f,
Signature (Owner/Agent) Date
PERMIT #
BUILDING PERMIT
DATE. VALUATION �!�ny LOT TRACTJOB
w +
ADDRESS 49 487 "VI��. C"t31�'(�T3'I,`�'ft�Cl.�'.
APN 649 x21,04*1
OWNER
CONTRACTOR / DESIGNER / EN (NEER
7Z is 1-mr DOAMON,"I'I TAIMS
CO SIMM101.4 J
PO BOX 1? 16��n2."',a
RWC110.1.A ,,U[HTAD%
LA QUINTACA 92215:3
LA CA qz=
(760)771-119,41 CRYA 96
USE OF PERMIT
MICKE FOAMY DWELLING
�� LOT I PLAN .Z"o.2�.tfaaYe.+�iZxT7Uti[1F'P isv2�C';�%,c"(3''ts+PCfl 1114i,;.t:.sUIZ, 0I,.�OC`.X -
iS€�
t9 t7'
v�}`.F¢LI Ny f04 `SMA F,a�.UFa3v t;.W. .i c' "Y'"ii-��Aiii'tI. °s'. `i�O I''t.�tapl{`'7 L�'1F�N( 5'�I�.,.•
I�1?,C)1.tC'.i' 014 F01? MULTIPL,1�' 1SSjJANCi, al~ MME, PLKIN TYPE
MOW CONIMMUCTION 0*100 9F
0. O CRA1tPOR:I' '% ,tip v
I
Pl,,," C'kaIC1s Flt r': 101-000-1439-318*$303,. 2
A:9'11�3IC1k ir�a�ot�muw0 $13&s4
Erylyl;i?,'L,°ytt�`RIC��'A3;�ttttRE -
g10�y$.-f}yJ/iytE)li-4zo)-YF000
•. .'Y'.YeUlVbAdk1'.r�/. S07'=17VGiT'^Y.Ta`V�J a Bl.�iJ..VYi
ST t,)NQ MO T1004 PES o RM, :1P 1 Q 1-000-24.14ft gds 44
c3i�+nl7?���I�l�.k� ��i��i30d����63(tt; •�i9.G�1
DZVAn,OP1., IMPACT FEE
ART M KID14,,10 PLC - WITE 770 -000 -44:1 -WO $378;47
f
:aUB.-TC.i'!1A%.C'i1MMUPnOt"dAND PLAN CitxTrOX
lxms nm -PAW Fim
$0.00
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
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INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
v BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel z
70—
Combustion Air
Roof Deck
Exhaust Fans
0. K. to Wrap
=9=3 _
F.A.U.
-
Framing
6 _/,3 3
Compressor
Insulation
— • 3
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
�J�
Final
Final 751
BLOCKWALL AP ROVALS
1POOLS,-SPA'S
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 Q
j
Heater Final
Water Piping
Plumbing Top Out
_
Plumbing Final
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 AP ROYALS
Temp. Power Pole
Underground Conduit
Rough Wiring a
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
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