0304-124 (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
Date '17 '2''1- 122 Signature of Contractor
m"
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:
O I have and will maintain a ceftificate of consentto self -insure for workers'
compensation, as provided: for; by Section 3700tof.the Labor Code, for the
pyrformance of the work for. which:this permit is issued.
(�r5 I have and will maintain workers' compensation insurance, as required by
SI ction 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 ` 1,ATL'i .t�tf 14 ! Policy No. 1..611) 4 2.01
(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
C,ode, I shall forthwith comply with those,provlslons.
'bate: - Applicant , Y. -
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 Safety
for a permit subject to the conditions and restrictions set forth on This
application. ;y
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.
'Signature (Owner/Agent) ,' �' "' °- -� Date_,!_, `}
j�
PERMIT #
BUILDING PERMIT
<�A,
DATE VALUATION ��� LOT: _ TRACT bZJOB
SITE
ADDRESS
APN
/
OWNER'
CONTRACTOR/ / EN INFER '
�"%5'r64T ^.,.011,1!1l'vff.f�;.G �<'%iCq
i�IR1TC;.,U�M �J.��'�7E
7�T7
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COT Tt7
?7 -645t�MPE 1.50
CAyy&JSF_-1CA 92211
NlTT7rEMERT "A 92260
(76')77.2-13wU aiwx- 1.1311
USE OF PERMIT -
.;!°i•.r. ., ) 1. dk d4.;k ,fi.:i•S: iJYaJJ 1J41&:y Itis k.i J. if
1,100111 SRA OR DEIV EX" ARNTIQA(T�Q
(ARST C':fYlVa'3'R;[1CTION VNII2.si13 U
K*,OG Sir
0.#s.RA014- ". �2KDAT '' 4.0q, By
7e1'i1MAIND Chi' 91'OF 4;Oi."iY t lUMN
t".t�•<r3�2'RUC'flO'?! ;< i?. 20f-000-41 8 -MID $1,;J&50
t� f� O't'Rki;>>.L ;u ; �J i -(tt-�t.'a^• OOi2 X2735
t�LRr.Tu3�;fks�) i'}z 101_000m419,000
S7'l2i4+1n3 #440T1,034 13.�1
i"116DITHL9 1' i
r191
L�.:lV ��ShYPMR i�4?AA'l ?Z!� + .. y2,401. 01
ART IN PU.'NI. C NA. EZI REaiTT. 2,70-900-445�00 ; $ot4s
:FEF!' 139POS%'E 107-0W-430 319
C014,1rRTA,*T11CC;X6UM Pf AN C','h1E TC
12:5111 iRF?1NTV Tq.! 'Y'
50,00
MAY 2 7.2003 :.
CITY OF LA.GUINTA.
FINANCE DEPTlip
RECEIPT
DATE ' :q ��,.
BY r,
DATE F ED /0
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
etum Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
OX to Wrap
F.A.U.
Framing
mpressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Q
Final
Final
BLOCKWAL APPROVALS
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
Water Piping .
Heater Final
Plumbing Final
' Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances '
Final
OMMENTS:
of 0
Final
Utility Notice (Gas)
ELECTRIC PROVALS
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
Utility Notice (Penn)