0402-128 (SFD)U)
F_
CV C0
04 W
O �
t W
o Z r
O' O
LLIa�
N
Z
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
716 9.9 B
f Date �� a� Signature of Contractor ��•"""'� ""
i
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,
's.
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 ihsurance carrier & policy no. are:
Carrier ` P61icy No.
(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' compen sation,provisions of Section 3700 of the Labor
Code, I shall forthwith comply wit ose prov ons.i,
,,-Date: tri uY Applicant 0; . ,/ ci�93ssek`."""'.e
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/Ag"ent) , �� ,f �✓✓ '°" Date Zoo9l 1
BUILDING PERMIT PERMIT//
DATE VALUATION LOT OdIO2-7128 TRACT
;•�` �'��� `�•�'% '�s'Di 2.�)'l-� 139 _3t?4�7
JOB SITE
APN
ADDRESS•
X30 -M5 1i.rA TALAV."ON
77-210-M.
OWNER
CONTRACTOR / DESIGNER / ENGINEER
)OLL• 1,RarKE B DTC
M): L T3RO T'IM;IcL;3 IRC
73.121,K= NVARLHO0160
71-121 Fq=WARJ�TG-01 0
PALM I7:r&7T, ' Cik 92260
PALM URMT CA 92260
(7t;O�S14-3699 L'.4 3832p
USE OF PERMIT
MGM FAM -MY Y DUiTFM•L1 M
5flt2 ,1,OT 139,1sTII17ir'A•l"+ ask PERMIT DOES NOT INCLUDE /.
BLOCK WALLS, P004 SPA 012 D1i31t'E9FlbY APPROACH 15%'Rr1D C.T10X T`1)`
PLAN CHECK FF'` DUE TO 11%iUVI1Pi, E ISSI 14CE OF `,&ME PIAN 1 YP,,
CUO TOM (;014,STRUCTlt� N U.12.00 OF
•YY•
pOltdHI'.AsT.10
OARMOVURPOU 7.21,00 SF
PER KrrIMF SUMMARY
CONSTRUCTION FU101-000•'418-000
PLAN r,liEC ,'Ffv}y lt13- eta �a3 } 1 ru.
11'QOi( d+pti�.":`1:le FEE 101-000421.000 $169.50
ELP..CI'i:1f:.iQiL IME ` 101-000-420-000, $10.24
TdAla�PRE 101.000.419.007 52205
VRONC) MOTION `FFE • FMID 101-000-9,41-000 $30.13
MADING.VR { 101-000.423.000 X1$100
[�Rv�JPACpT , $7,405.00
Dtt ETTEL0yy
�yI>'t�71R �"9T
qp� t � j g� �,y n /�
�eRT 1,Atl ' V;�71:JC PLkWES - k0.tE81� 2,5YO 000- P45,00V
' Y,9VB-1\.7.1AL0 <'SLVD 1'-h,nRb1,V l-r.CME.+t'b
aOt4,91.4,23
rA *.� k'F.,T3�
$0.00
FEB 273 2004
CITY OF LA aQUiNTA
FINANCE DEPT.
RECEIPT DATE'
1 �G aIrl;
BYDATE
FINALED
INSPECTOR
INSPECTION, RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVA Sr.MECHANICAL
APPROVALS
Set Backs
Underground Ducts
Forms & Footings
_
Ducts
Slab Grade
a
_
etum Air
Steel
OF Z7
,ombustion Air
Roof Deck
O.K. to Wrap
_ _
_
_xhaust Fans
F.A.U.
Framing
Insulation
_
0-0 Compressor
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
BLOCKWALL 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 APPR VAL
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
k-
Gas Test
-�
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring 4D 0
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors _27 -
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: