9611-043 (PAT)LICENSED CONTRACTOR DECLARATION
Cf) I hereby affirm under penalty of perjury that I am licensed under provisions of
f– Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
C\1 W Professionals Code, an"d my License is in full force and effect.
F) Z License # Lic. Class Exp. Date r
� "'
' W 314032 13 .� !'i 1 :?0
W ,
r
Z ir� /Date d' ft,. t�( Signature of Contractor - •/n,
T O !`�_ t,-,,,,... •- .r
�Z M OWNER -BUILDER DECLARATION
11i LIJ I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ Il 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). .
( ) .l, as owner of the property, am exclusively contracting with, licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
Cl) () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
OC
d Z WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
ir
n O () 1 have and will maintain a certificate of consent to self -insure for workers'
K W !:� compensation, as provided for by Section 3700 of the Labor Code, for the
DJ Q performance of the work for which this permit is issued.
Q 0 ()�) I have and will maintain workers' compensation insurance, as required by
U Q Section 3700 of the Labor Code, for the performance of the work for which this
L Z permit is:iS160. d My,;.-Wo–rkers' compensation insurance carfier%+`policy, no. Brie:
Carrier Policy No.
_cb O
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 agreea;/if I should become
subject to the workers' compensation ppvisionssof _S•e4a1/if
3700 of the Labor
isi
Code, I shall forthwith comply with those provons. l'
Date:1.. i� 1%;.. ,• Applicant-
Warning:
pplicant Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000;,in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees. ,
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and 'restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person ai
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnity
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null'and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and stat?/thaft the above information is
' correct. I agree to comply with all City, and State,la s relating to the building
construction, and hereby authorize representativeslf this City to enter upon
the above-mentioned property, for in p�tgon;purposes.
y t
/Signature (Owner/Agent) 4..• (` Date Ael
BUILDINGPERMIT PERMIT# CONTROL#
yn��3 4320
DATE 1111:51% VALUATIONS8 � 0 LOT, TRACT
JOB SITE
ADDRESS 49-375AVENi0A Flf.RINj�4NDO
APN Cp'l-341-11.6
OWNER
CONTRACTOR / DESIGNER / ENGINEER
-057.5 A.VriN DA FEEtNANDO
5M45 AVENiDA Vt1LLEJO
LAQU£N'I'A CA 92253
LA QUIN%.A C:A. 92253
USE OF PERMIT
(Ji NERAL iJU.It,Z1141 i,;
61.6 8..F. LIMIC"E PKI710 C<00.1
s�c.3lec:t�.rr���t..ty - htbuu ar
ES T1 rtlX117 CD C, 09r d) .F CONS`1`RdJM 6.00
PLAN c.;HU-CK. ) ERC,
fy'�s�iS'i'ftlfG"TiCSN:fG ILt�-Ot?i$�QOQ i�lti.!Jf�
h;';.'t�`iaf;�iv,`�a'Yti73vd�it•1'�:E:�ia lEsi�3ti�••`x�ii-iHl(} S+.&2
SUIB-T'UVAL CONMRI_ICT(t1N AND PLANI C'b•Ii;M
$170,02
LESS ��RE1 . Ph�3.1J �C'E -`S
$0.00
TO'.Q'A L PF,4 11IT 8+"EEN OVE NOW
317!1,02
✓
RECEIPT,. C r ..:DATE-
. _ _
BY
DATE FINALED
INSPECTOR
a
INSPECTION RECORD
OPERATION DATE INSPECTOR
BUILDING APPROVALS
Set Backs
Forms & Footings
Slab Grade
Steel
Roof Deck
OX to Wrap
Framing
In$ulation
Fireplace P.L.
Fireplace T.O.
Party Wali Insulation
Party Wall Firewall
Exterior Lath
nr,&van _ int i ath
OPERATION (' DATE I INSPECTOR
MECHANICAL APPROVALS.
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans & Controls
Condensate Lines
Final
Final /
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. 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
COMMENTS:
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 (Penn)
�- .. ..__..__.. ....
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�pp 1 T eElOw ORADE
IVUj �G'Q 17 � 750 � �i it�1 S
OPEN LATTICE PATIO COVERS MAY K ATTACI= TO COVMC FASCIA U -STRAP OR AN
VIA ONE 1/,C x S LAG SCREW rNROUGH FASCIA MTD EACH RAFTER TAIL.
NON-CORMOSNE
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I DATE
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(1} 1!!d WKS
Opltt DOLT •
PROVIDE Y CLEARANCE
OEr*M POST ANO
U -STRAP OR ANOLE
Mort
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PROVIDE Y CLEMANCI
acnvml POST ANO
CONCRETE
TYPICAL PATIO COVER
DATE OF APPLICATM
MOM NMIEMorm
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CITY. ST 2P
TEI.EPIIONE .
H.O.A. APPROI X S* MTURE. DATE
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