0208-204 (PAT)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury 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 # Lia Class Exp. Date
" Dates--' Signature of Contractor {
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 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).
( ) 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 maintain a certificate of consent to self -insure for workers'
compensation, as provided for by Section 3700 of the Labor Code, for the
performance oiLthe 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 STATE FUND Policy No. 393.01-001064 4
(This section need not be completed if the permit.yaluation 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, manjner so as to become subject to the
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation pr4vis qr,+s-of�Section 3700 of the Labor
Code, I shall forthwith
with comply with .thos'e p o�isions.
,,Date: 1 1-. Applican
It
Warning: Failure to secure �Workers' Compensation coverage is unlawfultarfdj
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 state1hat the above information is
correct. I agree to comply with all City, and State,) laws relating to the building
construction, and hereby aithorize'�representatiues of this City to enter upon
the above-mentioned propertyifor•insppe tion.purposes.
" Signature (Owner/Aa nt) A Date ,r_ ' f / s°
PERMIT#-
y BUILDING PERMIT 0208-204•07
DATE VALUATION p. LOT TRACT
JOB SITE ADDRESS 7#1 -tom tSAGU :t�:t) DWY0, APN
OWNER CONTRACTOR/DESIGNER/ENGINEER
1d1E,LDDY FIMAW.1 G ;1UCAND S3t":"f�'.�°+i.N A10 AMN.lNG
78-645 SAGUARO Jif" E 80-661 T..MWY :1,'1' ' C'1.
LA QIM1 U l CA 92233 IND110 CA 92201 {
k851066-2200 CB14 4996
USE OF PERMIT
PA310
194 S. F. LATTICE A.LUIVIAWOO 7 P.AT110 CO VOR, PER ePPWV&D PLANS
r'0RMPAT10 1 ,60 SFS
PLAN C;g I CK M, 101-000-.439-318 935.10
CONd°t'%i1C'iION FEE 10 1-000-418-0W $54.00
ST.RUNOMOTIOri x:11- 1E111D tQI-0001,241.000 S130
e
ni �r, 1 � 2002
I CM of A
RECEIPT
i
S`LT.B-7'tYTP1a C;C>NMUM.1024 .Mi PLNd' C. UX
IMS PRE -PAID FREM
S O 1l s'. , JL k,,R6,EW d A•'.�' ES. DUE NOON
DATE I BY DATE FINALED
INSPECTOR
$89.60 +
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 Q/Z_
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 . ?_ v
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 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:
.0 9
13
1160100 100 e.A
-7"clio �Al
F -IN.
PE
A RE -INSPECTION FEE OF $3
Ao WILL . BE CHARGED IF THE APPROVED
PLANS AND JOB CARD ARE NOT ON
THE SITE FOR A SCHEDULED
INSPECTION.
NO EXCEPTIONS!