0105-101 (RR)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
625038 C39 081,31/2(
Signature
81 1/2(
nature 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 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. .
have and will maintain workers' compensation insurance, as, required by
Sidc-tion 3700 of the Labor Code, for the performance of the work for which this
permit is issued. Myoworkers' compensation insurance carrier & policy no. are:
Carrier.- Policy No.
STATE -M4 D:; - _ ,. _. •anti (1: 06,02097-. -
(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: Applicant
_Wffn1n_g: 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. 1 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.
Si ner gent) Date
BUILDING PERMIT PERMIT"
DATE / VALUATION LOT 0105;401 TRACT
/O IV4,2500V
JOB SITE
APN
ADDRESS-- �—--------- "
7 11%79 WASHd1` GGT IT,S-
OWNER
CONTRACTOR/DESIGNER/EN (NEER
LEDER EFjT -IOWA?SON
CUSTOM i?OON1t,11-3 CO.
4E-81 1/796 YVASIT '`iGTOD AT 33—IR.EET1
8-980 FULN CH 01,ClS C0 0"iT-73
LA Q11n4TI . CA 92253
L4DIO CA 92203
(760)345-3751 12
USE OF PERMIT
GFI.TE_RA.L B U1LLING1-
B iUIL•T UP. RE.RQ01F. CLr.SSn. .. ,
- VALL'I�.T101,.
4,250.00 LS
FSMIA-TFU COST OF CO ST1 LTC 10N.
4,250.00
PE RMI' FEE SIT -A 11MAR.Y
REER001 FEE .101 r(-�1`c'•:Cii)€1 _ 4#ft,�i
SLTE-TOt t% • CCNI ST�r-.LTC''` (3iv A ZD PLANT CHECK
- LESS P� E�Pt.LT� FLEE
$0,00
TC3TaT pFVFtTy"? F�FS3i N(}Vk0:Of]
RECEIPT
DF- BY
�J
DATE FINALED
INSPECTOR
S
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
Date Signature of Contractor,r.�-�'
J
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor''s
License Law for the following reason:
( ) : 1, 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.
(.) I have and will maintain workers' compensation insurance, as required by
Seaon 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. .
SfiA79FTiN1�tlt:�fffl2AtYJ
4.
(This section need not be completed if the permit valuation is for $100.00 or less).
O 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 w. rkers' compensation provisions of Section 3.700 of.the Labor
„f h
Code, I sha , rtith comply with tho p provisions. r .
Date: ^ Applicant r _. m,., 7 ,•' ,y" r ;;
Warning'Failure to secure Workers' Compensation coverage -is unlawful and
Shall subject an employer to criminal penalties and civil fines up to $1,00,000, 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) ��^�p�*% Date
�r
s
BUILDING PERMIT PERMT#
DATE ! VALUATION LOT 0105-101 TRACT
s J/
JOB SITE
APN
ADDRESS
48-81 W95 WMIMMON RUM,
OWNER
CONTRACTOR/DESIGNER/ENGINEER
�'a.��y 'ARt?a,411110co,
48--81 11795 WAST- OTON iIMT
38.980 RANCHO LOS C'qYMM
'L& (VIMA C.A. 92253
1_fi DIO CA 92203
_
(?60)345.3 751 clivi) 12,
USE OFPERMIT
VERM14a, B Y✓VV
61.:11.T VP k2&1=1� MhSSA.,
VALUATKYR
�`pp�nr:�'ll�a `�`iD CCDS OF C.€�,116MUt"•' ON
4350.00
�y�•� %�p 4Hv- �{`r{��..�nq/�J�
ION
uk5' oy :F.EV, VA -M-4181_000 SAW
C
R MJ jf .�'oi s > . C't r • . 'LSA
pLESS F PAX)
M AY - 8 200T01 Mff �� N D= Ow
CITY OF LA OUINTA
FINANCE DEPT
mm
RECEIPT
DATEXF
BY
DATE RIVALED
INSPECTOR
II`
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 / C
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
L9
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I
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
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
_