0311-195 (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
7"077-599 4130104
Date' 7?l /9 _ Signature of ContractorAx
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 4he property; am exclusively contracting. with licensed
contractors to construct the project (Sec. 7044, Business &;Professionals
Code). -
O I am exempVunder 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. provi6ed:for by Section 3700 of,the Labor Code, for the
performance of the work for which this permit is issued.
• ( 1 1 have and will maintain workers' compensation, insurance, as required by
Seion'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 ..LIBERTY MUTUAL Ir Policy No. • W.4062i700$°:23f112T%
Q (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 sh II fo. hwith comply with those provisions.
ate rz j Applicant , 1
Warning: Failure to secure Workers' Com ensation 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
fort 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 anal 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 informatiim3is
° 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 irispection purposes.
Signature (Owner/Agent)i1r:��g✓.K�°—°
1. . BUILDING PERMIT,,. PERMIT#
DATE VALUATION LOT' TRACT
., =SMA) 142 30357 r
>'ir / • I.
JOB SITE
ADDRESS
APN n ry
OWNER *,f
CONTRACTOR / DESIGNER / ENGINEER
T va�Gi t�C3Trr�
'lOLLBRITE3C
7N, w.14yVR1140 100
f3-121 TMORD VARy4.0100
JDAVei MEWI C.A. 9.?,260
PALM DEPT CA 921160
x"/60)674*94599 f,'BVP 3832
�•
USE OF PERMIT ` ;
1 r41
4PD o LC)T 141 'VFIq xANr-,.IvLor;ta4. PERMIT DOES 140-1 Iii CLUDE
�.r�v��, i��.1�L,�,, F�c�O%,,:51s,� Ott i�R1V�W'�,�' ,,f�:Igltc3,�.�i•1
GtT T gym 0011S7'.RUan( 1q- +4,364.00 OF
qinY�.Cg�tti1�.A�'T�••�h����:'
t.?i3,rti,ers./�(�a.�Ai'LPORT � 9.�� OF
�`
:ESTMATIP.A. COST OF CON SIXIMC ZION 36209M
r.0] ffirmyl'AR-Z
CONfi1'3tUCTION n-9 101.000a�11i3 000 $3,560.00
PLAN Cii.F..Cic").r ' I O t -iitlil-/i 9-31 b $1, 6��.61
•'��1z�Y'i.ASIICJ<1�.'i7YJG. ;0150;30�'lziPd100 zi��,�.�
• �L.�.C'� It1G6►lt lrE• 1; � GlS-f3fi(�•�20-�i0�d �29.°1Z
.,PL 3M_B In FEE 101-000-419-000 $213,00
S RONO MO! 1011 FEB ° RESI 3 101-000-241--000 1.336.29
ORA1)MO FRE 101-000-425-000 VISA
T)EVEl..OP R MA -PACT FEE
ART IN, PUBLIC PJ ACES • RESNI r 270-000-445-010* $407.26
LESS PR&1?AYD.Y14;6Z WOO
DEC 17 2003 , 'sDTmnow S6,279.1A
CITY OF LA QUINTA
FINANCE DEPT.
GJ• . '
of
RECEIPT
DATE,r .'
BY j
D E FI➢aA D
I PECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts 07)
Slab Grade
Return Air—
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
,�
F.A.U.
Framing
_
Compressor
Insulation
_Ilk
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_
POOLS = SPAS
BLOCKWALL APPROVALS
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 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
r —
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Ali
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)
u