0301-299 (RER)LICENSED CONTRACTOR'DECLARATION
I her ffirm under penalty of perjury that I am licensed under provisions of
Cha (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and thy License is in full force and effect.
License # Lic. Class " Exp. Date
73 ,1.32 DIRC 3/31/03
Date Signature of Contractor
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).
A( ,) 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 re so
,Date X .� Signature of Owner .�
WORKER'S COMPENSATION DECLAMATION 6
1 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
S ce tion 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:.
Carver STAT:; (1AP, Policy No. 04601UNI4'-N09413
(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 shall forthwith comply with those provision r
bate: I .At -. r -? Applicant _ %_._
Warning: Failure to secure Workers' Compensation coverage is unlawf2a<nd
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 persori 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 pu pdses.
Signature (Owner/Agent):^` -_ - DDate f < qt $" 3
( --
• BUILDING PERMIT PERMIT# •
DATE , / VALUATION ��qp qq ��pQ}��qq ���2 1� LOTS TRACT
f7.0."p9�3VfAdrvc3�}
�y
JOB S4fE
ADDRESS .I.tct��Y1 :1 �fO�iI�� ^ 1G`.A4d4
APN
OWNER
CONTRACTOR/DESIGNER/EN (NEER
�1�'�'f'Y�'; , �4 �"., 3.1 C
P-1fcpa^^���t .11�
'LMI. i�vrySr�,�ytr�PAXwdWIC'}pGEy';t���`+E�'��� L 4��r0�1��`�y�`.!?A.�' 01
�.ryyr�.�S i�'(1y�r
r.6. xi t, x d S�"� o
2533 hYOrol OVER `. O,W ; Dd �.".Gt,S���;J. PYiP-:9.7 M -E. 250
ZA QU:4Yd`1 A CA 92233
CAMOTIFFBY77,11111.419A CA 92,00
USE OF PERMIT
MORAL UT=D
BIX0. 39- 54w9S7, 5444 , 4�Y3� Q.I.i1IJY'���tX
STRUCTURAL ODIRMIONS
VA:1r"t1.ATION 14,10.001, 3
31�`�MM'IED C9SM OF CO1:�iG:r",C`1�UCUMN
14'W901) .
CO1,fSTRUCTIOIN PER 1411.000-16.000 110100
S`I RON0.440 IGN FEE- tESW . 101-0000p 1:-0DQ $1.46
D Q D !�
FEB 0 3 1003
CITY of LA QUINTA
FINANCE DEPT.
MUR-T AL CMAi�.i�2UOM ANT. PLA3': �`i' 1`aM
$1$4.413
lags Pft4?i6TTS+"i�Cti�
7CCYTAL VEMT FUN DUB HOW
01MA10
A
RECEIPT
DATE/
BY
E FI LED
IN OR
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
'
Dr,mall - Int. Lath
i -
.r ^
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
Gas Piping
.al
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
COMMENTS:
-
t
.
Final i
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
F.I.
.^-
coke Detectors
temp. Use of Power
Final
Utility Notice (Perm)