0303-022 (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
rn�
Date11�°1"IT 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
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 iFtHY!l:`j'Y,MUTUAL Policy No. WA262DW4n347;`FT
(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'srhhall forthwith comply with those prouislo s.
Date: sr� Applicant "' //�./� rr.r.vlt�, ..�-- ---
Warnin,'g-_: 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 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 building
construction, and hereby authorize representatives of this City to enter upoin
.4he above-mentioned property for inspection purposes.. -
J !.
Signature (Owner/Agentjlk,�`d,�j? ��•%��"�--��""”" Date "We -Al
BUILDING PERMIT PERMIT#
/ Ofl 02�•
DATE (Ir /� / _7 VALUATION S �a LOTTRACT
42 303
JOB SITE APN
ADDRESS 80-37b VU VALENNA
OWNER CONTRACTOR / DESIGNER / ENGINEER
TDI. a, MOTHYR8 JNC °t Q L BR(XCHM.1 ]KC
3-I ZYN=WARMG'41aG 73-.12).P?-J_?,PWARt!' #1{0
['J•lS.e66. dJ. IS. r CA 92260 PALr"ui:.L M, Qlrf !-'.t1. 92260
(760)674 9599 tu'.sl* 3W,71
USE OF PERMIT -•
31q) ., LOT Q. P,;~;•2 , IT DOM.' 1H(;2.,L)YX BLOCK WALL,5,POO''.y
SPA Oq WNWAY C$1 0 CI 10 TA h3 A - t�
CUSTOM WNWRIXT.ION 'YjA2.00 OF
�irtc;t-fif1',6y�Ii�
3�C+.ti+� Sly
l KF�t V.A�,i�1'Oit`fi
614 90 8F
'
1
Y9XVTrd'sr;"F'
C0N0`rRU� TI051a YL?E
10).000-418-000 0.418.000
SLUD.ttt)
PLA 18 CHECK FBI E
10.11 _000A 3 9-3 1a),Ct
s f.8.2 `
I�i81f:AS_.
'jot
P111IM:i:?.11d0 FOP,
101,000419-000
$17JA
5n4Y3la m a:rud-w F:,VE ® ftsfv
101 .000-2j,k') -000
$28,24
t3%3J,;i9;1•00 FFR
101.000.4,23-00.1
£1g:00
1DFaVXWP).'?3 IMPACT FEE
$2,4us.oe
A11`§1 Pi011L:4:+Ea:.`I'°yl:."10y41Ef3G�4��r^GOc?
$241a,i�it
APR 1 R 2003. V, r +WIA+!•i 3I TPIIJ's XXTE HOW
CITY OF LA QUINTA
FINANCE DEPT.
:RECEIPT DATE ! A BY: DATE ;PECTO
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS .
Set Backs
Underground Ducts
Forms & Footings
Ducts
_
Slab Grade
Retum Air
Steel
Combustion Air
Roof Deck
0. K. to Wrap i
Framing
Exhaust Fans
F.A.U.
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 �—
Final
Final_
BLOCKWAL APPROVAL _
_
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 •30 0 3
Heater Final
_
Water Piping �i „_
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral ��
Sewer Connection
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notic4: (Gas)
ELECTRICA AP ROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final JV
Utility Notice (Perm) -