0303-028 (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
B 4P3ti, E13
Date y f� �� 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
cuntrdetors t0 C6h§truct 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 requiredby
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,1TSf�ft7yy 1 V1ft1Ai. k": Policy No. WAxfgL?Z 0047230120
(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 fill f with comply with t os p AAlsl s.
Date: �'� Applicant�"'"�^
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.
1'
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 upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) ` Date
BUILDING PERMIT PERMIT#
li?3tDX028
TRACT
DATE��// VALUATION42,;19 33, LOT 80JOB
SITE
ADDRESS �.i9iiA
APN
OWNER -
CONTRACTOR/DESIGNER/ENGINEER
!1011, BRODERS TRC
rol.L BR-onm-8
73.121 IMM) WARD4G I W
73-121 M ikl•.A
PAIM MIMI* CaA. 92260
I!F1%.dd1 DA10117MI CA: 92:260
C76-10)674.9699 CRIA 3637,
USE OF PERMIT
M?ITO LE1?fs'#vMICD'1�r ."Y:1IG
5.1110 . LOT 8D, Sigh x'14 A 1 PRA1111'1' 1,30&4' WC. T INCLUDE BLOCK
WAWA P(.X)4 PA OR Ci'It:TVEWAY 4PPROACH, 75% IdED'i1Gi' (W TO PLAW.
CHECK T)UE TO MULTIPLE ISSt3M4C?, OP SAME PLKN TYPE
CUSTOM CONS"rRUC-110W ZO9D,00 M?
PORCHMATIO 775.00 'IF
GARAGRICIMORT NON ON
NT11 .A.11T) ECt�a'rT (XV CrQ:�►.a"�:1��i'i"!7�` .010
�y •-gi�ypp�.vg� ��;;vv{{�����, pp X u�
S k[S.iY,1d T', .75.1-. �1UNWA�ly
CONSTRUCTIONFU 101-0001.4.13.000 $1,108.50
PIAN CHECK MIZE 1(01-000-419-:318 VV.0
N1&CWAN 1CAL FEF 101-000-421-000 $11L50
3YA:1P,C"1'RIC-M 1 E 1 1 •f7tJfi-4241 Lr1�iJ �i16Fi. ;k
PLUM IN0. FC'.17 1131=0i1i��+ d 9>�XO 10184"DO
STRONO MOTION 7- Z o 1ZPUS ID 101-000-2A 1-10+00
COM010 RZE '101-000-423-000 515;0
DEVEWIPER IMPACT gF0,
ART IN PUBLIC Irls.AC1ES - IRESIr M-000-445-000 584,33
A4.
l-TOTAT. Ci3myrrR�+'G`no.'a.�1hm MAN C BEICK
$4,374M
�'sLT:
` .00
AL NOW
VX4SO
FAP R 2003
CITY OF LA QUINTA
FINANCE DEPT.
RECEIPT
DATE .r !-
f
BYq
DAT I AL
I PE
r, 0,r ,r
/ � v
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Ae
Underground Ducts
Forms & Footings
Z,, p S.
ucts
Slab Grade
etum Air
Steel
Combustion Air
Roof Deck
OX to Wrap
Framing
,�
Exhaust Fans
F.A.U. i
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
iFans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWA
L 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 LinesHeater
Final
Water Piping
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
Final
Utility Notice (Gas)
ELECTRICAL APPROPS
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 (Perm) -O
COMMENTS: