0303-031 (SFD)LICENSED CONTRACTOR DECLARATION
U) I hereby affirm under penalty of perjury that I am licensed under provisions of
F— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
04
W Professionals Code, and my License is in full force and effect.
O =) M License # Lic. Class Exp. Date
In
r w s/ ?77699 699 4/10103
o ZO �-, Date �d 3 Signature of Contractor'- 1
CD _
J U C:) OWNER -BUILDER DECLARATION
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ IZ License Law for the following reason:
Z_ ( ) I, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structureis not intended or offered for
sale (Sec. 7044, Business & Professionals Codc).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code). I .
M () I am exempt under Section , B&P.C. for this reason
L
N Date Signature of Owner
ON
d Q WORKER'S COMPENSATION DECLARATION
C) Cr I hereby affirm under penalty of perjury one of the following declarations:
Lo � O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W �= compensation, as provided for by Section 3700 of the Labor Code, for the
O � Q performance of the work for which this permit is issued.
m Q C) ( ) I have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
It z Carrier 1,113ERTY M -U T UA.L FF: Policy No. WA202DOD4723012TC
cb D
r C3
J (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 shifll forthwith comply witlh1, t,�os prp I s.
Date: y ✓� U•� Applicant Vii . � �,�--f--��'
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
the above-mentioned property for inspection purposes.
' Signature (Owner/Agent) '"''mss Date
BUILDING PERMIT PERMiT/F
DATE (� VALUATION 150 LOT 0.103-031. TRACT
u
JOB SITE ADDRESS %.Kk V"Jr!A ;1 4CX1�%�
APN 772,2513 -Of f
OWNER
CONTRACTOR/DESIGNER/EN INEER
Tou.,DRarFrm.s WC
T01:, .BR0*1 rV . B.]NO
73.121 FRT9D W.&JZi 4GA100 . .
73.1.21 F RW 'W'AIWO 0100
PAI.M DE' SI 'I' CA 92260
FPAL 'I 1:11 RI r CA 92260
('7160)674.9699 %13TX 3832
USE OF PERMIT
SID • LOT 9% 'Et::i70NAl RA. .HIMMIT DOF,-!`%OYANC:LI3TW BLOCX
WAL A P►OO4 SIVA OR I,iRIVR r'E4Y APPROACH. 75% REDUCTION TO
PI JPat CHECK DULI TO MULTIPLE ISSUANCE OF Se> IAX PIA11 TYPE
CUSTOM, CONSTRUCTION 2,890,0 OF
PORCHPRFL t'Io 273.00 517
4ARAOWC.P RPOAT 610,00 3F
ES'.f3ARAIX0 C0 I` 011` CCP7S'TIQT'dC'•'Ix4D1N
PRliMT 7+'3+1 W11 %IARY
WNSTRW"'TION FEE 101.000.418.000 $1,108.50
P1,AN CHECK YZE 101-1000439_318 sira.00
MECHAINICAL FEE 101.000.421.000 SI1I.SG
FLEC'TRWAL ME 101-00"20.000 $166,20
PLUMBING FEE 101.000419.000 $1€4.00
STRON10 MOTIOW 'bila - RESID 101-000-24'1-000 $23.37
(IRA."O1NO ".F 1.tI'I,-q00-X423-00ff $.5:411
13EVELLP rIR IMPACT FZrL $L,mnoo
ART IN ,PUBLIC PLAC S - RF.SIL 277 0-000-445 -000 $84,33
-n
SUB -TOTAL CO)48TRUCTSC1N AND 1y11.AW CMICY
$4,324.90
0
p 0T.LPIM-KITI $ ° T now
$4,124aO
APR 1 R 2003
CITY OF LA QUINTA
FINANCE DEPT. r r
RECEIPT
DATtt
BY
ATLE
I SPECT
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
_ MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
, 0
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
Framing
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
av
Drywall - Int. Lath
_
Final
Final '
BL0CKWAL A AL
PO ' S - 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
Heater Final
Water PipingPlumbing
04
Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
- •p 57
Encapsulation
Gas Piping
Gas Test
Appliances
Final -
Final
Utility Notice (Gas)
ELECTRIC
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)
L APPROVALS
/ ..
1
COMMENTS:
-