0205-279 (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 # Lic. Class Exp. Date
w=10 i 3 ! !:[�; 04f � W2(
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Date ,�� W - J xSignature of Contractor
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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 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 EX&M.PT Policy No.
(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 that if I should become
subject to the workers' compensation provisions.,of, Section 3700 of the Labor
Code, I shall orthwith comply with those rovisioms..,-,__
Date: �4' �"-•Applicant +'r
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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, indemnity
& 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 1
construction, and hereby authorize representatives of this City to enter upon 4
the above-mentioned property for inssplectron purposes.
Signature Owner/A ent'�"` 71 -%�i �r Date fir" ; `'
9 ( 9 )
`' " i ' PERMIT PERMIT#
BUILDING
DATE WvRla� VALUATION 26AOLOT TRACT
JOB SITE ADDRESS 4•4M C'A.LLE SA.Y41A 1 XREIARA
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
MW
!°I03.3'
444-•780 CALLE SA1.1'J'ADMERA,
43-(A. -0WXA8
LA QUINTA CA 92253
PAI" DEEM CA 92.211
('160)360-•3654 CB1.;1
USE OF PERMIT
PAM
438 SIP ALU A4 A.Wi 010 P.ATJ0 COVER
408A 3F
PLAIN CHECK FEE 101-000-439-318 5:2.65
:"C7NSTC, UC ,100 IFEK .+". 101-000-418-t1i1Ct $bolo
9TRO),410 MOTWH FEE - RESID 101 -000.241 -OW MA
8ZTB3 TCa. i(, C(-)N7rffl3C."N0X ANI) MAW CHI<,UX.
$134,19
, MY VP,?,Mff FEMRITHOW
0
CITYOFLAQUIRTA
FINANCEDEPT -r^
RECEIPT
DATEBY
"` , .:
DATE FINALED
INSPECTOR
I
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air i
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
'Compressor [
Insulation
Vents r
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
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final i
Water Piping
Plumbing Final ;
Plumbing Top Out
Equipment Enclosure E
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
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4
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)
CITY .OF LA QUINTA
BUILDING & SAFETY DEPT.
APPROVED
FOR CONSTRUCTION
DA A 1 D Z BY
A RE -INSPECTION FEE 'OF $30
WILL BE CHARGED IF THE APPROVED
PLANS AND 10B CARD ARE NOT ON
THE SITE FOR A SCHEDULED
INSPECTION:
.NO EXCEPTIONS!
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