0311-038 (SFD)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
7 7 1i 699
Date 4 Signature of. ContractorF<`'
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 exempt under Section B&P.C. for this reason
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 Labor Code, for the
performance of the work for which this permit is issued.
(k 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.
I 12f9ETt,"i f MUTUAL ''*IA26ZD004 *,VI,r E
(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 co ply with those provisions- -
Date: +/ - ^ Applicant-'
Warning: Failure to secure Wo,rkers'-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
,,.,Signature (Owner/Agent) Date t !'
., ., 'fir ,�
BUILDING PERMIT. PERMT/t .
DATE VALUATION LOT TRACT
JOB SITE
ADDRESS
OWNER
CONTRACTOR/DESIGNER/EN INFER
1*011L]3ROTMER's Wr_t
TOUI PRCw1a��. j up_
��-1k] X lttJil3�t�� 31m
I3.1�I � 1*%��1!1v it! 00
]PALM DEW.— �.k 9.'L260
PQM, DC,SiMIT CA 92200
USE OF PERMIT
V AUV ,V� :!':{VO.
SSD . LOT P 74 Dom Nf.:T 6wG'l.f.a?L± oL.i cm.-
WA1,16% POOL,
�,6� n� U .
JAN 0 6 2004
11 s:ti�:: tt'a 3-0.00 SN
�3 L�.a1'x�3i sC:.s:a Br ' ;iFk 1 05140 up
CITY OF Qi tNTA
FIAAN_r: DEPT.
.f
'.TI�°R'Jl� t:•Ca`�E' CD.i�' i:€y�.�f,.�il'��0�'
�:fi.�,°'�'i,�
;;��qq�•�}y�yqq�}�,����[r�. �'•y�.r4"�.
S.tL7LYGY.i 1 t➢t�IL �M1A.,la:tN�^.-1�.j�T. -
00N0T.R. U CT 109 8.000 61,039,10
PLAN C.Ii1:C:K FEZ 101-000-439-31&. %-x 17
WCHANICAT, FEE 103000.421.000 $12k, 4
LI1 f RICA,L KtF, 901-000.420-0010 $157.99
PLUMVITHC Fait 101.�C�Ch"���;$•00`J. $1cA.Ut1
STAOX-0 MOT3ON.FEr. ;~7LOSID, 101-000-y;d2-060 �i2s"I.Ii4
O.t.�.DiN0 FEIR 1. 03 -000.4.23.000 $15.00
tJZVEL( PF -Id IAtig�►,i::i'"1.t� `�l if►5.00
ti.T Di Punic CtT. 11: v0 bw:•lIi9Q $49.91
co,wiiRutdyi tum Pug a7r•f--r,
$4y�J+.6.`�
Tar -OIL, PIRIAIT IFESS DUE now
$4 jV42,07
RECEIPT
DATE
BY
DATE 5fNALED
INSPECTOR
j.
INSPECTION RECORD
APPROVALS,BUILDING
%WWI)
•
` • 1
1
%1/"W► d, rJ
Final
BLOC
Set Backs
Footings
Bond Beam
Final
PLUMBING
Waste Lines
Water Piping
Plumbing Top Out
Shower Pans
Sewer Lateral
Sewer Connection
Gas Piping
Gas Test •
PROVA
OPERATION DATE INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills --1
Fans & Controls
Condensate Lines
Steel
Electric Bond
Main Drain
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Gas Piping
Gas Test
Electric Final
Heater Final
Plumbing Final
Equipment Enclosure
O.K. for Finish Plaster
POOLS - SPAS
Final
COMMENTS:'
Final. "
Utility Notice (Gas)
ELECTRICAL APPROVALS
Power Pole
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temo. Use of Power