0402-126 (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
777699 a 4r.30/04.
Date 'z � i ` Signature of Contractor�t
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)..
O 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 Policy No.'
74,262=4723012 TT
(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,
1 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 shall forthwith comply with thos provisions;
,Date -1•v /u . Applicant .J�
.Warning: Failure to secure Workers' Co pensation 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;' interestand 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) 0f ����/ /s��"""—"" Date G t
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
�r� t ryes t CCPhL-1`LG
Vit'
30-3.57!
JOB SITE
ADDRESS
APN
"15 VM *..rALAI
77-421,70-fi3d l
OWNER
CONTRACTOR / DESIGNER / ENGINEER
MLL B RCA:I.'RMS IRC
IfOLLL .E.R.0 11-M. li19 WC
73-121 F�,'RED Y76714INCT#100
73-121 FILMINARDT00100
PAI;M DESER C Cts 92260
PALM i3: MW R'1 CA 92260
(760)(74-9699 CBVf 3832
-
USE OF PERMIT
MN -Gly, ]FAM LY DV; wimo
SdaIJ P?,R.kIXT DOES N ?T IVt CLU09
13L0m,w.Aw% P oo4 spA oR,.'i.( wr,.wAic'_AF-xtPo.&cH
C:9s`%`OIv1 colls',f.ROCTIow :012.0 SF '
GA RAQ R/,CARP 0 RT OF
r
t,i�lU'�ED COST OF C{9.iV�i'.I'k?��.1�'°31011
3011291 X90
p �A!Sy
X"+d.'.19�.1716J.:1, �f B1. a �."7lJdPd l4J.AR d .
.
G.Cfr STRUCTiow PRE 101 -000-41 8000 $1.9316.90
PLAN aCHEC X P—Re 101-0004499-318 51,,iQ3,�5
MECHANICAL 1-128 101-000421.000 W9,50
ELECTRICAL FRE 101-0010-420-000
}'Io %4,1004011 10,1400419-000
'a" MN0 IMP'T IOIN FEE- l. Z41-000 �3f1.13
ORMANO KE 14
ART IN PUBLIC PLACES - P.&iE`2'M*0X0 )44S -00b $253.23
SUA-TOTAL C01MR.UM,10.14 AND PLAIN O'FMC IC
/A-\ a 1. 41 PRE -PAM RIM'
0,
D
L PE3iiis�Y,"V IFL1M DUE N'OW
Z.747.10
FEB 23 2004
CITY OF LA QUINTA
FINANCE DEPT.
RECEIPT
DATE
BY.
DA FI A D
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs _
Forms & Footings _ _ _
Stab Grade _
Underground Ducts
Ducts _
Retum Air
Steel
Combustion Air
_ _ _
Roof Deck _ _
O.K. to Wrap _ _
Exhaust Fans
F.A.U.
Framing
Compressor
_ _ _ _
Insulation
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 4
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 APPROVAL_
Waste Lines +
Gas Test
Electric Final
Heater Final
SWater Piping
Plumbing Final
Plumbing Top Out ✓✓✓
Equipment Enclosure
Shower Pans 0
O.K for Finish Plaster
Sewer LateralPool
Cover
Seaver Connection ��
Encapsulation
—
Gas Piping
_
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit 1
Rough Wiring
_
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)