0401-079 (SIGN)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions
Chapter 9 (commencing with Section 7000) of Division 3 of the Business ai
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
'
7517 90.31 C-45 £)1MIh'
D 1 " L Signature of Contractor'"�
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contracto
License Law for the following reason:
( ) I, as owner of the property, or my employees with wages as their sc
compensation, will do the work, and the structure is not intended or offered f
sale (Sec. 7044, Business & Professionals Code).
( ) I, as owner of the property, am exclusively contracting with Iicens(
contractors to construct the project (Sec. 7044, Business & Professione
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 declaration
() I have and will maintain a certificate of consent to self -insure for worker
compensation, as provided for by Section 3700 of the Labor Code, for tt
performance of the work for which this permit is issued.
( ) I have and will maintain workers' compensation insurance, as required I
Section 3700 of the Labor Code, for the performance of the work for which tt-
permit
tpermit is issued. My workers' compensation insurance carrier & policy no. at
Cartier STKYE, F-Lfffl) Policy No. 1?t1 64�
(This. section need not be completed if the permit valuation is for $100.00 or les:
( ) I certify that in the performance of the work for which this permit is issue
I shall not employ any person in any manner so as to become subject to tt
workers' compensation laws of California, and agree that if I should becon
subject to the workers' compensation provisions of Section 3700 'of the Lab
Code, I shall forthwith comply with those provisions.'
Date: l I ' t Applicant F cti-' i • 41f t - -" "
Warning: Failure to secure Workers' Compensation coverage is unlawful ar
shall subject an employer to criminal penalties and civil fines up to $100,000,
addition to the cost of compensation, damages as provided for in Section 37(
of the.Labor Code, interest.and attorney's fees.
1
IMPORTANT Application is hereby made to the Director of Building and Safe
for a permit subject to the conditions and restrictions set forth on h
application.
1. Each person upon whose behalf this application is made & each person
whose request and for whose benefit work is performed under or pursuant
any permit issued as a result of this applicaton agrees to, & shall, indemni
& hold harmless the City of La Quinta, its officers, agents and employee
2. Any permit issued as a result of this application becomes null and void
work is not commenced within 180 days from date of issuance of suc
permit, or cessation of work for 180 days will subject permit to cancellatio
I certify that I have read this application and state that the above information
correct. I agree to comply with all City, and State laws relating to the buildir
construction, and hereby authorize representatives of this City to enter upc
the above-mentioned property forvinspection purposes.
Signature (Owner/Agent) �t `"� Date 7 "
of
_ i,. -+ ,;� PERMIT#
BUILDING PERMIT'
1d
�,, 1-679
DATE VALUATION LOT TRACT
3,4I,Q�3
- r 7JOB
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SITE
ADDRESS 73h-4 i + AUGHW Y 1.3.1 .501` E S
APN _
OWNER
CONTRACTOR / DESIGNER / ENGINEER
157.A91110 MINKLCOr-. :W1T Co.
X. AA£; OTO ti°Ord' DIM. -WIN'
ART Co
3E56 VIA )D01.0
423 S CAIX—'VIT A, ST
s
Iv3ARWAID.6IL EY CA 90292
SP14 GNIBIR.M, " Cit
91796
le
(676)287-2512 MIR TBD
or
USE OF PERMIT
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CITY OF LA
9
QUINTA
FINANCE DEPT.
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RECEIPT
DATE
BY��'
D�E LED
INSPEC
J 7
_�
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
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I
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 VoRage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final /
Utllity Notice (Perm)
1
L
4' a' T
21
V 611
1
Approved bv:
❑ Planning Commission
❑ Cit*Council
QLZo'mmunity Dev. Dept.
Initials 116
CITY OF LA QUINTA
BUILDING & SAFETY DEPT.
APPROVED
FOR CONSTRUCTION
DATE1-1 Oy w.. BY4--= -
ONE SET OF ILLUMINATED CHANNEL LETTERS WALL SIGN,
IN 19" HEIGHT. RED COLOR WITH 3/4" BLACK TRIM CAP
AND BLACK RETURN.
LOGO SIGN IN 26" HEIGHT, RED AND YELLOW COLOR. 3/41
BLACK TRIM CAP AND BLACK RETURN.
SIGN AREA: W -a' X 17 -a'= 68 50.
So
mom ..... WIN .....
VI• X 2 KAM ANCHOR
NO LE55 THAN 6 FER LETTER
W,45%STAND
NEON TUBE
UY' FLEXCONDUIT
GM CABLE
ILLUMINATED CHANNEL LETTER ATTACHMENT UL LSTINGf 10M
ILLUG TR
.6UMADOAEI0r.E P.
.0. UL4&11D
SCALE
79-405 HWY 111 #5
LA QU INTA, CA.
Ilouou bale ciwaq ew;e a
La Oft CA 92253
IAuc Dihihe F. Clarke
Pit (160) 111-1668
I Fax 060 717.7687
li
CHINA WOK
DUNE PALMS
A-1
909 795-6855
P.
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Ilouou bale ciwaq ew;e a
La Oft CA 92253
IAuc Dihihe F. Clarke
Pit (160) 111-1668
I Fax 060 717.7687
li
CHINA WOK
DUNE PALMS
A-1
909 795-6855
P.
4'�#��''
_.._... _._... jt?t'�41";
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