0403-334 (PAT)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
HChapter 9 (commencing with Section 7000) of Division 3 of the Business and
C14W Professionals Code, and my License is in full force and effect.
O M License # Lia Class,,-} Exp. Date
o 481061-9 atae
Z r- Date y.' it Signature of Contractor
CID O r�
r- H� OWNER -BUILDER DE LARATIO4
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason: 1
Z_ ( ) I, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure isnot 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):.
LO
( ) I am exempt under Section B&P.C. for this reason
N Date Signature of Owner
O N
d Q WORKER'S COMPENSATION DECLARATION
p Zcc I hereby affirm under penalty of perjury one of the following declarations:
0 () 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 J Q performance of the work for which this permit is issued.
m Q U (/) I have and will maintain workers' compensation insurance, as required by
O Q Section 3700 of the Labor Code, for the performance of the work for which this
LO
rn I— permit is issued. My workers' compensation insurance carrier & policy no. are:
� Z Carrier Policy No.
ob O 11TATE FUND Ih?,M7.04
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 Califorriia, and agree that if I should become
subject to the workers' compensation provisions -of Section 3700 of the Labor
Code, 1 shall forthwith comply with those proons.
,.Date: �'� 3 '��ir' APPlicant
/ Warning: Failure to secure Workers' C62 sation 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
[�v�p & 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) Date �� 7
_ BUILDING. PFR, MIT ',PERMIT#
DATE VALUATION LOTTRACT
JOB SITE -
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
\a` Vdi�3,A"1`,.1 t.Lid0 K40 Ii C.Ja^S�CVk'tl.B
130. N0' IVSA Gyr-tM DE,
1450 , *>`1d'"M'1 %NT. 0-118
1A QiJUCA. CA. a22S?
c(MORA, CA 92882
USE OF PERMIT
.�A17U
112 S.F",&LUVI AWOOD PA'f f0 COVER.
}?012s"1'MPATIO MIN S?
i"
DtwQ TAKMtD `f�.,T OF �'i�.� SITI'�C;'.I:fON
211119
�1ry�^pg�]-�/j
'py $$ � t'' FIRM
i'LK9 CNECIK FRIM 101 _000-1139-3 18 $r►5.10
C014STRUCTION f E' 101-000.418-000 $4.00
5� R01-40 MOTION FEE - USID 101.000.241.000 Iso
r
MAR 2 3 2004
CITY OF 1A lmliiA6"fA
Fi;3AJ.
IMS TITMPATP FUM
TOTAL PERi1 T F—ItY.9 DUE NOW
RECEIPT
DATE.; r
By.
DATE FINALED
INSPECTOR
)
r'
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 & 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 I
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
Final
z
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fodures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
Dec: 06 2002 10:21AM P2
IC 30 EVALUAT 10K SMMCE, INC.
_ ......_ .. .
Evaluate . inform. Protect
5-W WoA=n WU tmad • W4f Wec CA id60l USA
866.4.iC6CyE9 l441.Z4JtJ wtljsee
911.699,0543 lora! - 562,693, 4694 ,Far
*w%6:bo"wrgvebSift a MaldboftAna-WW
February 4, 2002
Ceti Putnam
ER,2e21 P
Engtneedng Supervisor
Please refewca thisa number
AmeAmax Binding Praducts, Inc.
_ on all corwpondsnoe
1'�4a AK Pra L)r�e
ElhhtaM Wdtana 46694
Dear Mr. Putnam.
In reference to your recent request, the above -referenced evaluatonreport dated April
1, 2041, continues to be in good standing under the 1997 Unifoma Building CodeT'A,
)f you hart any gjeaftws, please omtect true at (%2) 83&0543, extanston 3260.
.Yours Vo y truly,
Brian C. Garber, S.E.
Prindpal Structure) Engineer
BCGAI
AMI
APLAC
?7ic onty "
iboatfv
.accredited.
r�Alk q
-
ProJac[
the US. r
1 PPODUCTc,,..INC
PHONE NO. : 7364035
_
GI'!� DURAL
X002 10:22AM P3 .