0211-051 (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
M1, 0/03
Signature of Contractoray �- �r✓-" "'
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). = t:
() 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 3,,IDHRT? <y g391'U},1, Policy No. i7VA2B2la00479I21°9
(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'hot•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 t:s all forthwith comply with those provisions.
Date n Applican -
-
Winning: Failure to secure Workers' Co rri ensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addltlonrto 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 Safsety
for a permit subject to the, conditions and restrictions set forth on .his
application' e'
1. Each person upon whose behalf this application is made & each person of
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.
Tcertify that I have read this application and state that the above information is
correct -1 agree to comply with all City, and State laws relating to the, building
construction,. and, hereby -authorize -representatives.,6f. this City to enter upon
the above-mentioned property for inspection purposes..
Si nature (Owner/Anent)';- --- Date At '
-BUILDING PERMIT PERMIT#
DATE VALUATIONS, ��gg;; p� ��77, LOT N, TRACT 7
PJnF9w
JOB SITE _ y-- --
ADDRESS WSW VJ VAa ,Moti
APN
OWNER
CONTRACTOR/.DESIGNER/EN (NEER'•
13-r•2q1 lum) VIMN(l.01oo
73-121 FRI-D ' ARTa'�7'G 100
"�
.2_760
PALM DESERT CA, 92260
(760)674.961,V GS3A 3t:*2
USE OF PERMIT r
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3?D - LOT 45,�QUINTA14A.-H. '10VI.Yv IT MES NOT NCI: MP, SLAXX
wtt-T 14, 4tC�t?.4 SPA BJP. DRMWAYAi'P,tt .+ACR '15%, I:iUCTit;N TO
Ail„,t%N CKFCK iia DUE, TO M UL71PLIe ISINUANCF tyle SAM I, P1,Ax "Fi+'M.
PC332f;111b`tE'fl'eE 520.00 S!:'
tGIf�2 la�3k'A�f.A .' Fa,�' 6219,110 3F
INi 7 +'I 1 C Caul' .ly Cfi INS111.1.
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•1.�rA�1t1(0:'�''SFa�r + 101-000418t,000 31120100 112 100 '
Pl:.AN cl-~i1C3'ra: IMM 101:.1000_419_ 18 $25946
MEC9i NICAL FREE 101-00042,1<00o $124.50
LPJ.,=9 .:.ICA.G VF3 1fJ1-01V-x•,20-000 Agus
P1a,bl i�GBTN-0 if°RIK 101 * 000419w000 11.170A
:lMORG MOTION ME -11=11) 101.000-2 41-.O(X) 174,24
CR.Asa NO RA? 101.000.,423.000 S1131100
TX1,, 1,i0,PETt INI RAC a Ml V4405.00
lkT IN MULIC PLACES - RUIE 270-000-445-000 $205190
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NOV lo 2002 r
CITY OF LA
FINANCE DEPT.'- -
RECEIPT
DATE
:BY
D IN
I PECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
A 3
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
*2 .a 3
Exhaust Fans
O.K to Wrap
(a, o %
F.A.U.
Framing
F7Compressor
Insulation1j,.7,_'Ye0
3 57
Vents
Fireplace P.L.
00
Grills /
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
S"OF. d 3 S
Drywall - Int. Lath
/
Final —
«t
BLOCKWALL APPROVALS
. 'nal
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 #PPR VALr,
e
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
Sewer Connection
Gas Piping
Gas Test
�-� %�_3
Pool Cover
Encapsulation
Appliances
Final
COMMENTS:
—
Final
Utility Notice (Gas) J� ��
ELECTRICAL APPROVIwL�
Temp. Power Pole
Underground Conduit
Rough Wiring n
Low Voltage Wiring
Fixtures
Main Service
_
Sub Panels
Exterior Receptacles%
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)