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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
74454.8 B 010 C1,127 H1 0)1/31/2(
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).
O I am exempt under Section B&P.C.°for this reason .h
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 LaborCode, 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 STAT ,nmD Policy No. 4FsWD'ER4992111602
(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,
"Irshall 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 37.00 of the Labor
Code, I shall forthwith comply with those provisions.
Date: a a:- Applicants
f
Warning: Failure to secure Workers' Compensation coverage is unlawful and.
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building.and Safety
for a permit.,subject to the 'conditions' and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursdant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
theabove-mentioned property forinspection purposes.
r
Signature (Owner/Agent)' A✓ 1t -,% i Date
BUILD_ INrG_ -PERMIT PERMIT#
.. `..,., J
DATE VALUATION — 'LOT. TRACT
_j g e�4}AJv.r 15/1 ' . 2197
'JOB SITE'i (/1 L/
4
APN
ADDRESS ^i�.00 JJSI. 1 �.O�i I e��
774-221-009
OWNER
CONTRACTOR / DESIGNER'% EN (NEER
WIUJArn J. PUT11
Ro*yp :. MAKcFN CF_, IXC..
54d1.1,00 X_t9k7CTROWFA lz7�•
42,600 C;AROLiN.1? COURT 01. D'1
LAQTJW A CA 92253
PAL.1M.DE5EPT CA 92211
(760)7'76-510' CBVf. .5309
USE OF PERMIT
0"AG-9 OR CARPOWr
t1A,1amakp d ,508 S1? n.- YJ :1, ` =13YY: OliY1'S'f'S tYO'YYOAI.
PERMIT DOES NOT INCLUDE BLOCK WALIA POOL Oil SPA,
GABA 3Z?lCARPORT . 34 .00 S1:
ESY'�Q)l�A7ITt',U COST OF C`0NS'ARVC"L$f41'4
6,10136JW
1E1r.ECTRICIf L FR 1 t11.00t n4 0..00ii� � 1, J li
STRONG PAO7'10H FEE • RE.SID 101-000.241-000. $.f0
'Plu N CRECK NER 101-000-439-318 $32,311
CONSTRIYCTYt,7N .. a�' .�, �1-t?Ct(3 �?•7 2t-iI00 k, ' $90.00
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2 2:2003,
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CITY OF Lim QuINTA
' FINANCE DEPT.
�i',� -`1°(x'1"RZ;; CC?2�';�'1"�C.T.YC'�Cal�' .i�,l�:i�j �%.�5?3:i.... < .[�
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IMS PRE-PAMY.E Es
$0,00
Ta �r , Pe a? s rs' arca
RECEIPT'
DATE _
BY, (
DA INALE�r
INSP T R
}
{ INSPECTION RECORD
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OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS.
MECHANICAL APPROVALS
Re
Set Backs
Underground Ducts;+
Forms & Footings 5
Ducts
t:
Slab Grade
Return Air
,t9
Steel
Combustion Air
Roof Deck (3
Exhaust Fans
O.K. to Wrap
F.A.U.
)
Framing
Compressor
has
Insulation
Vents
Fireplace P.L.
Grills
)�
Fireplace T.O.
Fans & Controls
€v
Party Wall Insulation
Condensate Lines
to;
Party Wall Firewall
Exterior Lath,
Drywall - Int. Lath
¢
CC
Final
Final -
POOLS - SPAS
IT
BLOCKWALL APPROVALS
steel .
Set Backs
Electric Bond
Footings
Main Drain Z;
Bond Beam t
Approval to Cover
(.
Equipment Location
Underground Electric
(�
Underground Plbg. Testa
Final
Gas Piping
€ L}}
PLUMBING APPROVALS
Gas Test
Electric Final ¢fit
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 It
;Gas Piping
f:!
Gas Test
Appliances
Final
Y
COMMENTS:
..
-
Final
Utilitji 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)