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LICENSED CONTRACTOR DECLARATION
J I hereby affirm under penalty of perjury that I am licensed under provisions of
I- Chapter 9 (commencing with Section 7000) of Division 3 of the Business and DATE
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
I JOB E
69 4899 B 8wfl)8 01ADDP
Signature of Contrac�:��
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
1, 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).
( ) 1, as owner of the property, am exclusively contracting with 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 hereby affirm under penalty of perjury one of the following declarations:
( ) I have and will maintair� a certificate of consent to self -insure for workers'
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. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
GMA"A' PLAIINS IN"Y' C 121'1�1 01
(This section n Bed 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
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those a
/15ate: .00 he_- /Applicant—
Warning: Failure to secure Workers' Compensation coverage is,unlawful and
shall subject an employerto 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
& h6ld 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 certif� 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
the above-mentioned property forinspection pu os
/Signature (Owner/Agent Date
OWNER
BUILDING PERMIT
i2mem VALUATION $206,5(116. 1() LOT
79-08.5 111C, ROM *FKA11,
&1fNI,1;'114r-1.U-PAir,rnn) covi% tN(,.
30445 100UNUAIN SIIAL�JWS KVI
LA WIN!"A CA 9 225.1
USE OF PERMIT I
PAKWX DWli.%HN,;7'V
PERMIT# CONTROL#
TRACT 4510
APN 769-55WO09
CONTRACTOR / DESIGNER / ENGINEER
Nil COW, INC.
50445 NIOUNrl'JUN S" DOWS KD
LA Q00rrA C'A 92253
CM -9 1625
:4-7)4,rjdk11T i.)4,_A7,_S W.) k INC-1:4ifAl fiLOCK Wikil. i_'sk POPL. PE-R�6T FUIN
REV1,11it,71' ART IN 110PIX; IA1.A(.*Wv (A0,*IJ1T(,+* 1264�,27 PER AORE-HKIENV
W1111 C'ONINAWITY
3,475XH) 3F
POR41 fit 11\130 SV
0 Alt A0W�,'ARJ1101<T' SF
EWUIMAXTED CUST MP CONSTRUMION
1*416.506. f 0
PEWWT 47EC M!NiMAM
FEE
10JAW-418-Wo
0.0,1101r,'All I.T.F.3
10 1 -(HX) -4,10-000
VON 67
C"
01 1 MHUNt'l VVUS
10 149.91-111 ".1-0)
7 lift
101 orCHKI414")
$1210,65
00
ul(AOINu
10 1 - �RW) -423 4"
r-4
INFRANTI K'1111XV
19
C-3
LLI
ART ) N III Ulf, 111` 01 AI'V,�,
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AND PtA'N CHECK
71
LESS PRE -PAID 171' E
4516,27
'1111ITAI,
PtRN11T FFRS 111MIE NOW
$6,790.44
ECEIPT DATE BY 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
Root 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 r/
Final
POOLS -SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground P[bg. Test
Final 11:7:z 1E I AZKOZ�'
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Sho\yer Pans
O.K. for Finish Plaster
a!jL4r Lateral
Pool Cover
-5ewer Connection Ci r-)
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Ublity Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
E)derior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Ublity Notice (Perm)