0304-297 (BLCK)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 # v Lic. Class Exp. Date -
, ' 630373 F3 ' 06/30`2( "
ate r' 2 Signature of Contractor"'' " �f
OWNER -BUILDER DECLARATION.
11 hereby affirm under penalty of perjury that 1. am exempt frem the Contractor's
License Law for the following reason:.
( ) -1, 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):,K010.T1 I'M URANC Policy No. VVC2 00P-02.2
(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 sd as to become subject to the
workers' compensation laws of California, arpdagree that if I .s ould become
subject to the workers' compensation provisions of Section 700 of.the Labor
Code, I shall forthwith comply with those Kovisions: .
/Date: `f"i`t% 6" Applicant � Rr �., .
Warning: Failure to secure Workers' Compensation cover/age 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,xand State laws relating to the building'
construction, and hereby authorize, representatives of/this City to enter upon
the above-mentioned property for Inspection purposes,
4.. -Signature (Owner/Agen/ Date
r
PERMIT #
BUILDING PERMIT
DATE VALUATION ! 'LOT TRACT
JOB SITE
APN.
ADDRESS 794, X-) V1 CY_'fA, t3FaVE
OWNER
CONTRACTOR /DESIG�NER�/yrN INFERR
Aizvr 7 LF -,Y.:
Boss CC'mmatim- 1014
79-115 VIC'10)I:1A 3:?ibVE :.
6s*iO YAJOV.RVidC8C3D DR
LA QTJM-TA, CA 92253
;PALM DESPAT CA
922.61
(".6 )349.337^s C,'337A
7,246
USE OF PERMIT
C�'EATF.:T'td.3L 2�U7.ti�1�7"Ai'o� .
8 L? 5' GA1k.DftN WALL'IT4CL'kJ1.)INO GATE 1EXAR SIDIr'.`St'ARO OF
HOUSEIP R CITY STAND
.l FT. VVXAU .. i9aVJ 11
ESTV"Ilym COST 0V COMMUC-TION
CONSTRUCTION FC� ,t�.7�Or?tiW41f�.:�t�ib . �ta.94
APR 24-2003
CITY OF LA QUINTA .
FINANCE DEPT
IRF ...dui
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3 '3S �'QF<'ACI 7'7IF 5. 'ti,t10
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Ait
RECEIPT
DATE/ ,
BY
GATE F NA SP TOR
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
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
-I& 03 Z_Tf
Main Drain
Bond Beam
R. c
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
m ef
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
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)
COMMENTS: