BLDG (0010-199)52430 Avenida Martinez
0010-199
LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of.
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
cv W Professionals Code, and my License is in full force and effect.
O =) M License # Lic. Class Exp. Date
w r— 381984 02.9 FRC _ ' % 07/31 /Ze
Z r Date 1 ' S gnature of Contractor— '
CD i
J U C) OWNER -BUILDER DECLARATION
W W n I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ a License Law for the following reason:
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).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
M () I am exempt under Section , B&P.C. for this reason
U7
N Date Signature of Owner
O
CL Q WORKER'S COMPENSATION DECLARATION
p z I hereby affirm under penalty of perjury one of the following declarations:
O () 1 have and will maintain a certificate of consent to self -insure for workers'
X w Y= 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 Policy No.
Cb Z)>?E+
O
J
(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
3 subject to the workers' compensation provisions ofSec &on 3700 of the Labor
Gode, I shall forthwith comply with those prov&s&o S..;0
Date /9 i'), /',,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 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
fthe above-mentioned property for inspeeti6n4purposes.
I/ Signature (Owner/Agent!+sf j''*' DateLl" /9 " V
BUILDING PERMIT PERM&TN
C10
DATE VALUATION LOT . - TRACT
JOB SITE
APN
ADDRESS !i2_4:'10AVEi Njy)AMA12_MFZ
_
OWNER
ObNTRACTOR / DESIGNER / EN &NEER
ADAM MAMI.f U,
SIC TdVnrMOCK M&GONRY -
52-430 AWMA EL ""
P.O. BOY. 12,459
LA QUANTA
PALM RUM CA 92255
C760)837-0289 MAO 5503
USE OF PERMIT
01KIMAL BU'.Ci ING
30 LF & SLOCK WALL PER MCO iZ3:'PAIL
6 rf, WALL 90.00 LF
FMAAMD COST OF CONSTRU'MMON
2,0MOD
CONSTRUCTION FEF 10rl-000- •1S-tJUO $45,00
COx PN'AWDMAN MUCK
$45.00
MIS PRE -PAM FSM
$0,00
Oi,T 2 0 200
_MS D OW
CITY OF LA QUINTA
FINANCE DEPT.
a .a®
RECEIPT
DATEf(/
{n t
SP TOR
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
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 /rj
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
W a Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Sha -ger 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
:jnderground 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)
5 Ti n1
w o 0 ) F .uGd
NSW
'Tv L ocK-
'moo , 1/10
c -L4
Iq0all, fYla. r/.
13 ` -o L -c,
CITY OF LA QUINTA
BUILDING & SAFETY DEPT.
APPROVED
FOR CONSTRUCTION
DATEo2 " 0 BY
4 v
1Z 6rN w A, L, C uJl 6i5-6,0 AJ
nrJ6
3
M
7
f
c -L4
Iq0all, fYla. r/.
13 ` -o L -c,
CITY OF LA QUINTA
BUILDING & SAFETY DEPT.
APPROVED
FOR CONSTRUCTION
DATEo2 " 0 BY
4 v
1Z 6rN w A, L, C uJl 6i5-6,0 AJ
nrJ6