0402-152 (PLBG)_ 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 ��t
?87503 B me 1 11301V
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:
'(\�Q) 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 exempt under Section , B&P.C. for this reason
Date Signature of Owner�f.' r /
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 Policy No.
P1 STIERTIED EMPLO` WK -1110819-1
(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 provisions.
Date:.,) ' (� ~. 1 Applicant—
Warning:
pplicant
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. 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 purposes.
ell
Signature (Owner/Agent) , ( l - Date
' f y.
BUILDING PERMIT PERMIT#
DATE VALUATION LOT tf4M-152 TRACT
JOB SITE
APN
ADDRESS
78-121 AVF'XW.&.LA FOrfDA,
OWNER
CONTRACTOR / DESIGNER / ENGINEER
I.�" 3 Co at:
:GgMG COrTST..°fit:iRl SERVICE
1A QTJD4 `A CA 92253
(760)771 -2384 -MA 04989
USE OF PERMIT
COI IAZEC ' S7Wf'fDIS11W.3Hi.R TO CFREA.SE tNTERCE WOR (A: 4DREVOS BAR
,%Cyd?,t€Y,)
VALUATION
E,'T FPJ K.M- ) CO.Ir OF ("M 15TSWT3'MON
40)UM,
.PIAIMi POO FEE 101-000.419.000 $27.00
FEB 1 3 2004
CITY OF LA QUINTA
FINANCE DEPT.
2 UR-T'C3 L T... CL2�iS' .R.1'C`T101 AM PLAY C7MCX
LESS FRE41 AM FM
RECEIPT `;i;S�,
DATE ��
BY
I D17%1
INSPECT
,. to
INSPECTION RECORD
r,
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS .
Set'Backs
Underground Ducts
Forms & Footings
Ducts
4 17
Slab Grade
1
Return Air
F ;)
Steel
Combustion Air
) ,`
Roof Deck
Exhaust Fans
'
O.K. to Wrap
F.A.U.
g
Framing
i
Compressor
i
Insulation 1
:;
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
{ y
Party Wall Insulation
Condensate Lines
I A
Party Wall Firewall
y
Exterior Lath
t
Drywall - Int. Lath
(5"
Final
i1
Final
POOLS -SPAS
BLOCKWALL APPROVALS
r
Steel
} It
Set Backs
Electric Bond
Vie,
Footings
Main Drain
(�
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
t
PLUMBING APPROVALS
Gas Testfi.
Electric Final
I
Waste Lines
Heater Final
Water Piping
Plumbing Final
t ,}
Plumbing Top Out
Equipment Enclosure
i t�
Shower Pans
O.K. for Finish Plaster
I r�
Sewer Lateral
Pool Cover
t i;
Sewer Connection
Encapsulation
k
Gas Piping
i{
Gas Test
Appliances
€ 3i
Final
COMMENTS:
71
Final)
Utility Notice (Gas)
q{
ELECTRICAL APPROVALS
Temp. Power Pole
i
Underground Conduit
'
Rough Wiring
Low Voftage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
{�
G.F.I.
Smoke Detectors
Temp. Use of Power
r
i
Final
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Utility Notice (Perm) -