0307-220 (CARPORT) LICENSED CONTRACTOR DECLARATION BUILDING
I hereby affirm under penalty of perjury that I am licensed under provisions of BUILDING PERMIT OV1 t'-220
I- Chapter 9 (commencing with Section 7000) of Division 3 of the Business and DATE VALUATION LOT TRACT ,+p 9'
04 U Professionals Code,and my License is in full force and effect. 1 r
S,?3,C 283 36
License# Lic.Class Exp.Date
o ILLJ O r 184-531 B C-� HIC rl i10 JOB SITE ADDRESS M-87:4�4�°'�I'ik)IF 47,(31-ARAM.Vtt? APN :'�4�•< ! :?�t4♦
Z � Date f 0 Signature of Contractors--•^� - �� .A OWNER CONTRACTOR/DESIGNER/EN INEEFi
CID
O orl- � tCYH ROEL 0,01,MEX.T,Cc3N CO.,��IC,
J U CIO OWNER-BUILDER DECLARATION 1.5116.f3132.MM,31ZiS'Yr - 784401 HaCiI A.Y:t 11 AS IA QT7'W1TN0A97TW
LU Wd I hereby affirm under penalty of perjury that I am exempt from the Contractor's 3,Jk QUINTA CLQ, 92253 $.{lN DIM40 C:'1, 97,'Utz-ot
U) License Law for the following reason: (619 :Zr-4.156 f.:SIL i 300
Z_ ( ) 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). USE OF PERMIT
( ) I, as owner of the property, am exclusively contracting with licensed GARAGE OR CA w?O.riff
contractors to construct the project (Sec. 7044, Business & Professionals _ _ _ _ M��-•
Code). f. NL.1. KW� tis. �W J .l D•w c:)f�.e)!v) i,R2 .f a..l�. tl.rr•rr V4.+p
co () I am exempt under Section
LO B&P.C.for this reason
N Date Signature of Owner
O �
Q WORKER'S COMPENSATION DECLARATION
o Z I hereby affirm under penalty of perjury one of the following declarations: O,p,RA01/C"AANDLIT OWN SO
Lo H O ( ) 1 have and will maintain a certificate of consent to self-insure for workers'
X U compensation, as provided for by Section 3700 of the Labor Code, for the
O _ Q performance of the work for which this permit is issued.
CD Q U I(ti)r I have and will maintain workers'compensation insurance,as required by
O 0 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:
.,t Z Carrier Policy No. VAfC1.Oft 61.4 )ik WIVID CIO.' XI OF COVI$1-NI1'Ci" ON
06 a FAUM FOR a xZUk
J (This section need not be completed if the permit valuation is for$100.00 or less). (1710 iSTRUCZ ION K"I't 101_001 -41 18"000 52411,0+0
( ) I certify that in the performance of the work for which this permit is issued, PLAN C''f{)CK_'Ft'M Irk M3 9
I shall not employ any person in any manner so as to become subject to the E1,EIC11"€ WALMX 1o1-0100.520.000 IMISO
workers' compensation laws of California, and agree that if I should become a'.•1!ft ,40 MOT,KDN FE It,,R.CS11.) 1031000-'241-6Ua $2,31
subject to the workers'compensation provisions of Section 3700 of the Labor Cls:IPa£?4';�t FEE03."X00-42,41LOCC $13100
Code, I shall forthwith comply with those provisions.
Date: 4 °T- Applicant
/Warning: ailure 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 SM-1-M,Iat. 0D11SS�"t".WtX''`i 0) -ANDM,,llr'TCaDECf,,,-
whose request and for whose benefit work is performed under or pursuant to , F _ 7:51a.9 ):h"JE'»ml!}x�;['.F I},0O
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. ' . VE ,.
2.Any permit issued as a result of this application becomes null and void if '1CCyAIG!�` � '`� '� �
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 1 - _ I IIIIII III I I I III I IIII 67
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, -- IE }
the above-mentioned property for inspection purposes.
RECEIPT DATE „BY DATE FINALED INSPECTO
Signature (Owner/Agent)¢ ---- ^� _ Date •,J! _
INSPECTION RECORD
OPERATION DATE INSPECTOR OPERATION DATE TINSPECTOR
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 17 XT3POOLS - SPAS
BLOCKWALL APPROV LS steel
Set Backs Electric Bond
Footings Main Drain
Bond Beam Approval to Cover
Equipment Location
Underground Electric
Underground Pibg.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 HE /1"
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)