0010-0279 (PAT)47750 Adams Street
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
at r " Z 0 ' iC.3 Signature of Contra
+ OWNER -BUILDER
I hereby affirm under penalty of perjury that 'Is 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
t 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.
(0/1 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.
LEMON rNSUR"CE
(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 a„ilree that if1„sheul become
subject o"the,,workers' compdnsation provisions of Sect'orf3700of/the Labor
Code, I shall forthwith comply Ath those provisiQr s
Date: If11. 6• bt -Applicant ' --- / / """"
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 compenbation,°damages as provided for in Section 3706
of the Labor Code, interest and afton4ey'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 herfby authorize reprRsentat'ves of this City to enter upon
the above-mentioned'Vroperty for 'Rspec Ion G'rposes.,/
,Signature (Owner Date (f '
BUILDING PERMIT PERMIT#
TRACT
DATE VALUATION LOT TRACT
VW401211i:
JOB SITE
APN
ADDRESS
' 47-750 4UeMLMTp
OWNER
CONTRACTOR/DESIGNER/EN (NEER
71N, AI021 C ORPOP ATION
, E" i ti G'r J0RAiG.1_J
5029LAMRfDRA L MERSIDE,.92307
5029 IAMM'DF A -L 'AIVEMSME.,, 925M
S'?"OCKI i M CA 0320?
ST'C.2CKPON CA. 95207
(702)753.3930 Gut. 5906
USE OF PERMIT
Itl3:710
4 "MADAS - 9 Q 2-b S. P. ; 1 512 R. -1r ; AS PIM, ,A kj? €(? 9 t3
,t
i~°GRMPATIO of
F
514XI'D COW 033.0 iCCO. 1'iw,l1R' 'f°'II 3N
1 jr., 4.00
p^(( q y, yp y,ry' '
ER
PIAN ONECK FEE 101.-00.4395418 91221",,
„
COWST RUCTION FZ1 101-000.418-000 $199.00
S'MONG DanMON FEE. irR ID 101-000,241-000 $1,70
S -TOTAL CONS'MUMICNICAMD PLMT CM—W.
$313.53
I as PI—PAW For.0
`0.00
TOTAL M"Wr VMS DUE Now
3.55
111111111111111111111111 35
IE
RECEIPT
DATE
BY
i ti
- .
DA FI ALED
INSPECTOR
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
POOLS - SPAS
BLOC KWALL•APPROVALS
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
COMMENTS:
-
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)