0006-117 (PAT)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjurj 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 r Exp. bate
f� 61.3%.5 ' � �Z[G° .•�7 � i• � .;�G� i�C
aD to f-� ' SI j nature of Contractor ' e/ ��++
OWNER -BUILDER DECLARATION
I.hereby affirm under penalty of -perjury that l'am exempt from. the Contractor's
License Law for the following reason:. r
( ) 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)..`
( ) l,'as owner of the, property, am 'exclusively- contracting, with licensed
contractors to construct the project '(Sec. 7044, Business & Professionals
Code). ` ,
O I am exempt under Section B&P.C. for this. reason
Date ` Signature of Owner
WORKER'S COMPENSATION DECLARATION '•
I hereby affirm undee.penalty of -perjury one of the;.following declarations:
(•) . I have and will maintain certificate of consent to self -insure for workers'
a
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
Section 3700 of the Labor Code, for., the, performance -of the work for -which this
permit is issued. Myrworkers' compensation insurance carrier & policy9 no. are:
Carrier... . ' Policy No.
r y:
(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 whicti,.this permit is issued,'
I-Shall-nocemploy any person in any manner"so as to become subject•to the
Workers" compensation laws of California, and agree .that if ['should become
subject to the' workers' compensation provisions of Sectlon'330rof the Labor
�C��e; Irshall forthwith comply. with those p;ov sion�s,.
►date:= ' J -�'� 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. r '
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., V 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) �� J'Dafe�
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 0006-117
TRACT
€h /12r2m • S3,192=
JOB SITE
APN
,
ADDRESS 19-6241a10r?M'G G1r.13HN C;U2
- -
OWNER
CONTRACTOR / DESIGNER / EN (NEER
WORLD I311 V LOW&ENT
L D.'P- CONWIRUMON CO.
74-333 HWY 1.11 ;TF_F 103
78-155 C, UXFOPi`1?URA
PPEMDUSERT CA 92260
LA Q1,T:"fA
i CA
92253.
('760)7'71.8071 •
C%L3#
6238
USE OF PERMIT
PAnO
240 SIP AI.UA9A'6 OOD RATIO COVER. 1C1109'2621P
PO!"tMPAT10 210.00 Sly
ESTMA',L'E-13 COST Or, CONS Wii7G".d'[OK
�y1.92.IDO
M YEE 8'C7M} "Ry
P14M1 CHECK FEF 101-000-439-318 $40,95
OUNSTRUCTION YZE 101-000-418-000VNI
r
STRONG MOT.1014 FEE - REStla 101.000.2-41-000 $ So
.61
Ali.
t.
t: 3.
SUB -TOTAL Cf XMUC 1014.4 D PLAN C;J i -rK
$104A5
LEW pk -PAID IMS.
$0.00 '
RECEIPT :
DATE
BY _ . 1J
DATE FINALED
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 IGr • Z Z -
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
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: