0303-040 (SFD)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
777699 B l 4130;'03
IJ
Date Signature of Contractor., •
�
v
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 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 i.,1.UMTY• 7s~1U' I.JAL K Policy No. IMA20 )00443012TI
(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 orthwith comply with those pro ,iSlons.
'Date: f�. ? Applicant'".
u
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 SafBW
for a permit 'subject to the 'conditions and restrictions set forth on fiiis;
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.
S gnature (Owner/Agent) Al) �. ', �—"' Date 1/ 'Qd�G
PERMIT #
BUILDING PERMIT 64.00)
DATE; / VALUATIONq� . ^ LOT 4 c� TRACT 01
JOB SITE
ADDRESS^: F� +IA'.+i5;7i4JNC3 APN
OWNER CONTRACTOR / DESIGNER / ENGINEER
��Y.'i �ft��'r.�'�.�t►ri i�`3•��;� .��.'/..1.13���J'I.�F?'.fit�SZa ��:'��%)
'12-121 FRED 'WAYdNG0.100
CA 9226 ' =` "a%aA DRISTMA, CA S12260
• %fssr7jf�'ir„c:�;c,�c� rL'�r..l� 3¢S;?�„
USE OF PERMIT
y:)�ir �A1Jr�»«y�6(, y7 ct(K'AAi,f& :('ryC>7J�N,L}Y�..a•I�tw t'r:..{Ara11 AJJ1,FY�.yx yi.4LJ A
iY'ALL.% F"V'\.,/.t, .V `4C1. byS{. A��'•'sl YTa ��•.�pi Z .�:f�f� �fO.OfTe s/ )•.:
iiia,
UAeI`AC3f1�lGPF!'c'.lt'j' WCO :S
. - •-+-`,� � n• n .� tt+!']Y�'t^++f'FPT�
11'�'.tir�l.��.l��.:B�� 1,9,F3d1 v�' k.•L..i�'t'0�u;14� wxr.er
�h>�_��. fl�
M,_r,...�.
I C^•�131�'S'R�SC'• J'it`'fd .�I:�'�
1(Y i �'�J00�& i S�aC�t�
�Y,41�
F'�a4rE i�}^.i�:C'l� �'Lr'r.
xGi-iiUfi•-�?�-3%�!?
pks3T."t9
,
Wt;i1. 41CAL HM
101,.GO-0 12,1 -o".to
S 1 ?PA
?.1a1�..;,TF AL
101.0111z0 -41D -OW
F1A11VFiR411"i ME
.101 r0(.i -419.000
STROND MOTIOV 1<1rh. M16
101XI )ID -M A OOL�
$3.'s.•+�i5
ORADING FEE
.00
S1�,OD
T.rl#.'Y1s i.4.)P31R i`JUliaAC,T PU);
c�,�if�4.fi0
ART M 7'ZjRAC )"1Ad.-'ROME 270-00f-445-000
Sa76,38
7 y {
lef-A ' CHFrX
1.f 13 P) 1'ATl E/s"1tai SCD,: o
AT; ry,42'. 'r Fla R 3:►ON NOW
APR- l -g 1,003
CITY OF LA QUINTA
FINANCE DEPT.
7 _{. •, -
RECEIPT DATA ` BY r DATE LED I SPECTO
6
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
,Underground
Set Backs
Ducts
Forms & Footings
Ducts
Slab Grade
02
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
OX to Wrap
F.A.U.
Framing
If
Compressor
Insulation
i
Vents I Of
U
Fireplace P.L.
Grills 11 Ilk
Fireplace T.O.
Fans & Controls i0d
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWA
L APPR VALS
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
7
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit1
Rough Wiring
Low Voftage Wiring
Fixtures
114
Main Service
Sub Panels
.000
Exterior Receptacles .0
ZWK
G.F.I. .10
Smoke Detectors 10
Temp. Use of Power
Final
Utility Notice (Perm)
11 w v/ �