0008-237 (PAT)'LICENSED CONTRACTOR DECLARATION.,:'.�. • ti; .
6, underpenalty of perjury that 14m licensed under,prowslons of
(commencing with Section" 7000) of Division 3 of the Business and "
als Code; and my License is in full force and effect.
Lic. Class Exp. Date
67 256 C -6i Ilr?t�, ' 10 1/2(
Date 19 0 ignature of Contractor
OWNER -BUILDER DECLARATION ��j
I hereby.affirm under penalty of perjury that I am exempt from the Cofitractor's
License Law.for the following reason: " ))/
( ) I, as„owner of the property, or my employees with wages a)their sole
compensation, will do the work,'and the structure is not intended odoffered for
sale (Sec. 7044, Business & Professionals Code). "
( ) I, as owner.of the property, am exclusively contracting. wiNi licensed.
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
() I am exempt under Section B&P.C. for this reason'
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I he'reby affirm under penalty of perjury one of the following declarations:
( ) I. have and will maintain a certificate of consent to self -insure for workers'
compensation, as provided for by Section 3700 of the Labor Code, for the
perfo ante 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. My ,workers' compensation insurance carrier & policy no. are:
Carver STATE FUND Policy No. 0460-VNIT i7749-99
(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,
1 shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California,yand agree that if I should become
subject to the' workers' comperisation�provisions of Sectiorf 3700 of the Labor
Code, I s all forthwith comply with-thbtse provisio L.
Date: Applicant n�
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 authoAze, rep resentatives of this City to ente upon
the above-mentioned property-fo inspec to purpoaes. `1
Signature (Owner/Agent ` Date
BUILDING PERMIT PERMIT#
DATE )q{�/�►/ VALUATION.. rp iyq LOT" TRACT
z
JOB SITE
APN'
ADDRESS AVXffMA J.ZAFZ
_ f
OWNER
CONTRACTOR / DESIGNER / EN INEER
WMMY. VXCTOR' •
ATLA11 AVMWCI WieANIt:;
-,330'..V1�tMA
754 WR�.5 ROAb
,= U#ITA C..A, 92253
PAL1%4 SPRINGS CA J`92264
I
(760)327=8466 l OBLO 1825
USE OF PERMIT
PAi P
(1) 126 S.F/(1)220 SJ /(1) 212.5 S.F. AI..UUA`aNOOD LAT'TICIE
WHO COVER PER [COO # 2621 P
PORCWPATIO 126.00 SP
POR.OI-t►PATIO 320.00 Sig '
PORCH/PATIO 212.00 9TH
FSr1W4A rF.D COST OF C0X9rRVCTI0-N
7,421.40 -
PkV1IW TME ff uhlmAny
PLAN Cp1W-K ME 101.000-439.318. 104.35
PONSTRUCTION FU .101-000-418-000 $99.00
STRONG MOTION FEE - "SID 101.000.241-000 S.74
P
AUG 1® 2000
t
8U1.3-TC?TAL C 0RffrRU( 1100 MD PLM CW= y
$164.09
Us US PRF -PAM FEW
$0.00
TOTAL F'YS_ME1* FMSI D17. NOW
$164.09
RECEIPT
DATE
BY �q�y, y\��4jj ��
DATE FINALED
INSPECTOR
r
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
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 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
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:
Cl0scD
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