0303-029 (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 t�5 Signature of Contracto
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
rnntract4ro to oonotruct the plujeut (See. /U44, 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 1,1i:t+ri2TY MUTUAL Y Policy No. WA262D004rk.1 +12'11
(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 forthwith comply wit . those p vI.. - 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.
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
A above-mentioned property for inspection purposes.
Signature (Owner/Agent)%i - Date
PERMIT #
/ BUILDING PERMIT
DATE j i� —VALUATION $233,73330 LOT � i TRACT
JOB SITE
ADDRESS' W,
APN
OWNER
CONTRACTOR/DESIGNER/EN (NEER
Ta S., Eita'3a:t s mm
'YOU, i3RCiTMRB JIM!
33.1.21 FF..` 'WAFX1401 100
13.121 RM WA 0 IC*
.PJUY i�Y &4`MT CA 92260•-
•� PAU1 DESP:CT C.A. 92260
. C160)674,91699 Mix, 3832
USE OF PERMIT
=013 FAMn,.y OWL. ULIM
SP'D A Lf t' 81, StrD ON;P •A. Pit;RMI'.:D0k,11VUT FNCL?JUL' Ff7.00K
WALLS, P0014 SPA 011. T?1i1td'RWAY APPROACH. 13% REDUCTION TO
P"AN CHECK JOUR TO Ii Ut.TIPALE ISSUKHCF, OY SAME i?1.AN TYPH
CUSTOM CO?1S'#'11,WITION ,U00,00 aFP
.PO CWPA'TiO 275.00 SP
GARAWCARPORT 610.0013F
!K 't 1TJKQ "r WKIV OF CONVIRTAI'DON
233,-m—%
PERM. TIME StrAMMY
CONSTRUCTION FEE 101.000-418.000 S1,19�,50
PIAN CVuCi". 1ZF 101-000-439-3-18 $227.00
MECHANICAL TeES 101.000-121-000 $111.50
ELX "lAIC..a1,FEZ 101_0 0-+120'000 $i6b.�t3
PLUMINO FE 101.0040.43.9-000 $184.00
.1TRONO MOTION F'SE.. ID 101 -0130 -241 -MO
ORADINO FRE 101-000-4-2:4-000 $t5 tl0
DEV .LOPFS'R I'M MCI' ftrY S ,405.00
Alra IN PUBLIC, PLACES - R41F. 230x000.445-(000 $84.33
a�
z:
SEM-T01.1-AT,tmy)` '.� "t.? �t;"� FOI ANDPULAtt_���' e�"If ,pp�:qq
$4,12fi+f�'.C9��prQ��
YK
APR 1 2003
CITY OF LA QUINTA
FINANCE DEPT..
RECEIPT
DATE
BY
EFINALE INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
Framing
A.U.
Compressor
Insulation
7 Vents in ct
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
240
hjwL
Final
Final
BLOCKWAL AP OVALS
PQQ $ -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 Unes
3
Heater Final
Water Piping
Plumbing Top Out
i
Plumbing Final
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
rj- - p3Zr7Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICHAPROVALS
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)
dM I
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