0307-217 (CARPORT) LICENSED CONTRACTOR DECLARATION PERMIT#
I hereby affirm under penalty of perjury that I am licensed under provisions of BUILDING PERMIT ;'?-,2!'f
HChapter 9 (commencing with Section 7000) of Division 3 of the Business and DATE VALUATION � 1 LOT TRACT
WProfessionals Code,and my License is in full force and effect. �4S"Q � ,5 24`30
O =) M License# Lic.Class Exp.Date r
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C4%, ,� JOB SITE ,t i+ APN
LLJ �81`s,i. 1. 4%7110 7131/04 ADDRESS 7#7V i ANLT& 7�Q�'RAtiF 4 64N-09"14
4
}7 t j t < �) `~y~ OWNER CONTRACTOR/DESIGNER/EN (NEER
o ZO ti Date Signature of Contractor- -- -
� — o ( $ICIPH ROM,,CO",MI ACTION C:i7,1N'.'.
(0 OWNER-BUILDER DECLARATION
16 BUPC;fBMI 'ITRT.11 78,401 3 11011f t%Y 11).:45 J-4 4?LaOT A C A 9Z !,3
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
F- (` M ;+ y;�S� ;� ,�Iilt;(?t� C:t Y.48-01d
U) License Law for the following reason: _ -
Z ( ) I, as owner of the property, or my employees with wages as their sole f613.?'T""11•4156 C"•VI nC7
compensation,will do the work,and the structure is not intended or offered for
sale(Sec.7044,Business&Professionals Code). USE OF PERMIT
( ) I, as owner of the property, am exclusively contracting with licensed C314t7-AGE OR OATZ'>Ol 'i'
contractors to construct the project (Sec. 7044, Business & Professionals
Code). kl u OgIAQM , r.r rr,,v N c,c.• �s c
LO ( ) I am exempt under Section , B&P.C. for this reason 1?F0fd?',TD FTE PF,tttY IT OF A914
N Date Signature of Owner
ON
Q WORKER'S COMPENSATION DECLARATION
0Z
� I hereby affirm under penalty of perjury one of the following declarations: QARi�MARI"ORT I.$ ;00 BY
r- FZ p ( ) 1 have and will maintain a certificate of consent to self-insure for workers'
X w �= compensation, as provided for by Section 3700 of the Labor Code, for the
m � Q performance of the work for which this permit is issued.
Q I have and will maintain workers'compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
'IT Z Carrier a iph amtrivo Policy No. 11IC3676619-0 WMxAI'VI)(110 .t*Wr CO•NS 1,50)(M1 f'N 36,495.20
Ob 5
Q (This section need not be completed if the permit valuation is for$100.00 or less). COPSTRUCrI014 Fry. 101.6}( -4 j e-000 1330.M
J ( ) I certify that in the performance of the work for which this permit is issued, PLAN CHZCK"Y. 1!!t-000-A Y 03.ti3
I shall not employ any person in any manner so as to become subject to the gF,,LZ(fTM"FRI, 101-000-X120.000 15:.24
workers' compensation laws of California, and agree that if I should become S'a.:.ON0 M a 1 did "Z•RX ID 101-CILIA-s-41-000 $3.61
subject to the workers'compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions. Ct1iADRIG MOMS 1 U I_Wrrl"23-000 $15.00
,.Date: 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 allR-Tf�J1"R,j,C0...14"P ITC:'f'I014.f W.,PIA14('`4 M11 5463 14
whose request and for whose benefit work is performed under or pursuant to LYP3 ALT?_;-PAW NT.9 $0.00
any permit issued as a result of this applicaton agrees to,&shall, indemnify r"
& 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 TDTAL P f(PEES DU h UAV S46',A
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 _ I IIII I III I III VIII IIII 64
' correct. I agree to comply with all City, and State laws relating to the building I
construction, and hereby authorize representatives of this City to enter upon `_ IE
the above-mentioned property for inspection purposes.
RECEIPT DATE BY DATE FINALED INSPECTOR
Signature (Owner/Agent)---_"�- --' � � Date 4 t ; .3
INSPECTION RECORD
OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR
BUILDING APPROVALS MECHANICAL APPROVALS
Set Backs Underground Ducts
Forms&Footings — — y Z& Ducts
Slab Grade Return Air
Steel Combustion Air
Roof Deck Exhaust Fans
OX 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
BLOCKWALL 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 Gat 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 Y7 Pool Cover
Sewer Connection V 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)