0304-218 (PAT)LICENSED CONTRACTOR DECLARATION
U) 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
N W Professionals Code, and my License is in full force and effect.
O =) M License # Lic. Class - Exp. Date
t` lY / 260484 -JJ 1 . fJ1 ldi
ZO � Date GI [ 116A It1.) Signature of Contractor A)(
J U C:) OWNER-BUILDEkDE`CLAR'ATION
WW I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) 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).
C'') () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
Q N
0)
Q WORKER'S COMPENSATION DECLARATION
IL
C) 2 Z I hereby affirm under penalty of perjury one of the following declarations:
U-5 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
O J Q performance of the work for which this permit is issued.
m Q U ( ) I have and will maintain workers' compensation insurance, as required by
Q U Q Section 3700 of the Labor Code, for the performance of the work for which this
0 Z permit is issued. My workers' compensation insurance carrier & policy 6o. are:
Carrier STATE'FUND Policy No. 229440-2904
cb Z)
0
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 tha f I should become
subject to the workers' compensation provisions ions of Section 3700 of the Labor
3 Code, ! shall orthwith comply with those provisions. j
Date: =1 �a 1 Applicant r ) 2 ( A /
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to crimi al 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.ailCity; aqd State laws relating to the building
construction, and hereby aurhorize rep resentativespf'this City to enter upon
/the above-mentioned property for inspection(/purposes.
` Signature (Owner/Agent) Date
,, t.�,
BUILDING PERMIT PERMIT#
-218
DATE VALUATION LOT TRACT'
LM/9E 1 tit $4,628. .. 42 25953
JOB SITE
ADDRESS 44-820 CALLS, PLACMO
APN
(�i-(YiA OSi'7
OWNER
CONTRACTOR / DESIGNER / EN (NEER
GEOFF JO'rIA 014
P"�T EZ°iF�t. CG3Ia�"Z� t1�703� .. '•
44.820 QkLIE P ACCDO
746918W. � Y t FW,'_R AAD
1.A QUfNTA CA 92253
TCE1011SAIM PAIMS CA 922; G
('760)275-6017 MVi 3106
USE OF PERMIT
PXF-0
348 aF.alT Uh4'AWO0:D '1 ATT1CL+ PA.T10 COVER
PORCH/P.ATIO WIN By
NFS'�1".W:i'.M COST OF CrORTMi'3MI.ON'
4���R4lI
PLAN CH G`2. FEE .101-000-439-310 546,56
CONSTRUCTION RUCTION FEY, 101-000-418400
STRONG MOTIUN FSE - RIGID 101-000-241.400.
D
- p�R .18.2003
CISY OU14; TA
sII.i3-wm COAT maja. om AND PLAw mm
$119.30 .
TMS PRE -PAID PERS
$0,00
TOTAL YljFRMX� ,FJKL�S'DUE, now
$1194W
RECEIPT
DATE����/
BY'�
DATE .INA' LED
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
oil f)
Final
FinalL 0
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:
q"Bao co,�k, -ptccickc)
Lo, C,,4
Son rfscl
V�ce eco -Ho
(,0 uer
CITY OF LA QUINTA
BUILDING & SAFETY DEPT.
APPROVED
FOR CONSTRUCTION
)ATE B