0211-048 (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 # Lia Class Exp. Date
93 B 4430fO3
to 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 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
Se ion 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 ,X t� 3>3IJ 1tr'1IPolicy No. W.i%,7.QD0Q4W340!2TE
(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 s : all orthwith comply wi hose pr isi ns.
Date:/�I �' �" Applicant ' �� '
Warning:;Failure to secure Workers' 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 forin 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'fo�180 days will subject permit to cancellation.
I certify that I have readitfiis 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-hereey authorize representatives of this City to enter pon
the above-mentioned property for inspection purposes.
,-Signature (Owner/Agent)-1 L",- Date,%
BUILDING PERMIT PERMIT#
DATE VALUATION LOT _ TRACT
JOB SITE
ADDRESSlt�e.Of3',
APN D 1l
OWNER
CONTRACTOR / DESIGNER / ENGINEER
73.121 M7;. WA_H. 34.3fa 00
73-121 SLED 10P;F.N1114101 0
PAU�k DIMERT CA 92260
PAI 1ADMER.27 CA 921,260
USE OF PERMIT
SWQUf.r-AiAlLY 'DW X400
SIFID =• LOT 3NOL„INAo-A PERMIT DOES' 0T-fNCLU,0,fs 1ILOt: r '
WAWA P004 SPA Oso MUCG T.O'N `I'&KAX
CH.F5.,CK PFP,' DQ9 TO MUL T..TPLA IS3UA:NCIE, 6VT;t MH, P1AV 'ri 1M*).
CUSTOM ONLOI'i.CiUMdRYN 3110.09 IV
t�t�dRCI=il�.E TIG 3'.Siixo Sir y
ESTIM, E~1D C''C;Igr CXV C1011TITTR SC' (M
27.5,019.5D
00340Tr UMON P-? 101 -000-4 1
PLAN CH&X MME 101-0001-419-:31
301-00-421,000
Xt. `f`R,IC,r I., f: L9 101-0 00-14-20 000 �1eta.F+RT
Pl.tI'At N14C# VEK 101-000-419-000
STRUNG MOTION .FE Z . T2.&SITJ 101-000-241.000 $.4e7, Sc,
Gij?Ai iINC} i RI?, � �! X00>� �;3•(�U�1 � i °�,�p
D.TE'MOMM It,4P. C -T ,.I';
ART IN PUBLIC PTAC°;E5 - k.$ tis: 270-000.445-000 87 -MA
�.. "O #'t"Rxi'��'�.`Xt�l�'.A'k�I91s1 J�1 r"`f t CT;
9,'4,M:1.43
1=95 PRE -PAID RRE
tf,
NOV 1 1 02 r°1 ail
MIALF KW+Yf:��:�:ENDM O
S4,647,43
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CITY OF LA QUINIA
FINANCE DEPT.
RECEIPTDATE
t
BY DA
IN ECTOR
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INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
jq
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Z kw_tsExhaust
Fans
0. K. to Wrap
3 -all's 96
F.A.U.
Framing
S
Compressor
Insulation
• o
_
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls 00-00
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
v
Final
BLOCKWALL APPROVALS
Final
POOLS - SPAS
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���
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster r
Sewer Lateral
Pool Cover
Sewer Connection
A -Z -,-dP .ze
Encapsulation
Gas Piping
Gas Test
_ejn�-
Applianges
_
Final
Final
Utility Notice (Gas)
ELECTRICAL A PROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring /
Low Voltage Wiring /
Fixtures
Main Service /
Sub Panels f
Exterior Receptacles j
G.F.I. _
Smoke Detectors T
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: