0301-354 (RER)LICENSED CONTRACTOR DECLARATION
�I hereby affirm under penalty of perjury that I am licensed under provisions of
'CH$pter 9 (commencing with Section 7000) of Division 3 of the Business and
J'Professionals Code, band my License is in full force and effect.
License # Lic. Class Exp. Date
7 3315 2 113 MC' 03/31l2C
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).
((,.) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals.
Code).
( ) I am exempteunder Section , B&P.C. Ior this reas
�r
Date % �f�: �1'� ;)� Signature of Owner.,:,_ c� . ^
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 STA Tp. VVI-NID Policy No. 04901U)411`0094la
(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 1 should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I s all forthwith comply with those
Date: �� - Applicant r^ --
Warning: F ilure to secure Workers' Compensation coverage is unlawful- 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 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 inspeecctio purposes.
Signature (Owner/Agent)`((
BUILDING PERMIT PERMIT#
(/
DATE VALUATION' LOT�t���ti TRACT
JOB SITE
ADDRESS FS l n�.�r�Q! - 1.;.+i'b'1"ff21
APN
OWNER'
CONTRACTOR / DESIGNER /EN 1NEER
PCIA,WE ALry!WDAL ASSN
DEL MAR.yACCI^V MINE -RAL nN6R/, MI
P.O. BOX 1060
2533 SGUIRCOf4,S''TM%).WAY 91TE, 25CP
LA QUATrA. CA 92259
CAT-0107BY11DIMA CA 920w;
0760,1635.1010 C21514f 5923
USE OF PERMIT
ORNERAIL
SLD0 16: 34,8997, 55-9.93 3446-9, 544435. V'Oi..UINTAkY
&lT UCTUM MOD11''I ATION9
VAILU-ATION 2000.001AS
O COST T OF C0N1.r n C;':'x): 3X
20.00,00
pyRgRGIM"'
�•L�•Y+T+A A� .4�li1� e.���w:wnRvr A
COl STRUC°s' 101 i RIF, 101.000.418-,000 $207.vo
3110NO MOTION YZZ W RESID 1'4.1-®p0-��'1.000
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FEB 0.3 lK
CITY OF LA QUINTA
FINANCE DEPT.
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RECEIPT
DATE!
BY `
DATE FI �A
I P OR
i it
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 APPROVA S
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 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
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:
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CERTIFICATION OF COMPLIANCE To the best of our knowledge, ad, of the reported work, unless otherwise noted, '
ubI 'M#!ids With approved plans, specifications and applicable sectioons of the building codes. This reportcovers
' 1e Iopado5ixrork inspected only and does not constitute engineering opinion or project control.
CERT: NO. �S�g � TI� � �6� INSPECTOR NAME loot� S�rAVCA/
1--. C941 AIR14 INSPEC'iORSI
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AVETEAVEN
Page of
Inspection Services'
PROJECTJ)&A Wr-
67- Lj=e sjbt PROJECT #' 6Aw-3.O
ADDRESS Sy-JW4 {' e -'#i7 CLIENT Pew; kjr.5-'"
Alah
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BLDG. PERMIT #
ARCHITECT <;"A A
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ENGINEEQ��
CONTRACTOR) 'G. ,All
o4j' /-hcfen C
INSPECTION TYPE
INSPECTION REPORT
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CERTIFICATION OF COMPLIANCE To the best of our knowledge, ad, of the reported work, unless otherwise noted, '
ubI 'M#!ids With approved plans, specifications and applicable sectioons of the building codes. This reportcovers
' 1e Iopado5ixrork inspected only and does not constitute engineering opinion or project control.
CERT: NO. �S�g � TI� � �6� INSPECTOR NAME loot� S�rAVCA/
1--. C941 AIR14 INSPEC'iORSI
} A DAVE STEAVENS
Inspection Services
PROJECT ;��A JdC57-1_E6f.Ub5
ADDRESSSV-a'q-; 8 9.4443,, R 9'7
IfJV&1Qi65 JaLb&4` 14 4.0
BLDG. PERMIT #
ENGINEER :1) t. .,J SA Jo q-,
INSPECTION TYPE
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Page of F
PROJECT # 00 3 - U 9
CLIENT
DATE {t7 Mi 1 t.. duo �
ARCHITECT C70L. d o4 A ¢GM
CONTRACTOR 4;_ L W44 r�lgr_
INSPECTION REPORT
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CERTIFICATION OF COMPLIANCE: To the best of our knowledge, all of the reported work, unless otherwise noted0 ,:M
substantiallgcomplies with approved plans, specifications and applicable sections of the building codes. This report covers "7
the locations df the work -inspected only and does not constitute engineering opinion or project control.
CERT.NO. INSPECTORNAME _-- �At% �•.� ,
'DATE _14 !i AK't' '064g_3 INSPECTOR SIGNATURE
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CERTIFICATION OF COMPLIANCE: To the best of our knowledge, all of the reported work, unless otherwise noted0 ,:M
substantiallgcomplies with approved plans, specifications and applicable sections of the building codes. This report covers "7
the locations df the work -inspected only and does not constitute engineering opinion or project control.
CERT.NO. INSPECTORNAME _-- �At% �•.� ,
'DATE _14 !i AK't' '064g_3 INSPECTOR SIGNATURE