0312-149 (AR)LICENSED CONTRACTOR DECLARATION
U) 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
WProfessionals Code, and my License is in full force and effect.
O 5 License # Lic. Class Exp. Date
oZ r Date I �'� Signature of Contractor
I.-- O
J CID OWNER -BUILDER DECLARATION
WUJ 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
N Date Signature of Owner
p N
0)
Q WORKER'S COMPENSATION DECLARATION
C) CL
2 Z I hereby affirm under penalty of perjury one of the following declarations:
Lo �fr-
p () I have and will maintain a certificate of consent to self -insure for workers'
X W !L compensation, as provided for by Section 3700 of the Labor Code, for the
O � Q performance of the work for which this permit is issued.
C3 Q (� (^/�/a I have and will maintain workers' compensation insurance, as required by
O U QS@Ction 3700 of the Labor Code, for the performance of the work for which this
LO H permit is issued. My workers' compensation insurance carrier & policy no. are:
"t Z Carrier Policy No.
oo Mi STATE FUND 1471037-1DD
r` 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 agree that if I should become
3 subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those. rovisions.
Date I t Applicant—
Warning:
pplicant
Warning: Failure to secure Workers' Compensation lverage 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 l 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 for inspectior�purpo es.
Sig` a ure (Owner/Agent) ^(\ Date t ��
,
BUILDING PERMIT PERMIT#
�12����
DATE VALUATION LOT TRACT
A, $5,42c)Ao 4.8 24890-7
JOB SITEY
ADDRESS 79-1/00 C11RU
APN
7tt9-'i �
OWNER
CONTRACTOR / DESIGNER / EN (NEER
WOfr13RYAN'
t EVEG3MSOR C0N8 R1JCrf0N
79460 CTIRUS
PO BOY 1616
LAQMNTA C.A. 92253
IYUCCAVALLEY CA 92296
(7617)365.6435 CB:0 'MD
USE OF PERMIT
10J1D 's+1' LkL A1JDix`1:CIN
ADDITIONAL 84 SF PATIO ENC:IDSUR.E SUPP'LEMENTAL TO PZRMIT
031.1.248. HOA APPROVAL CONFIRM. 2001 C'W_
CUSTOM PATIO CONVERSFCIN M.00 3F
E S YDAATM COST OF C 01 S R1UCnOK
5,426.40
IYERA Ai"[" PER Sd'TLiWfl.RY
PLAW CHECK IT -E 101-000•439a318 $32.65
CONSTRUCTION FW, 101-000-418-000 $81.00
II.LLCT'R1CAL FEE 101.000.420.4100 s i 6.5o
STP..ONO MOTION FEi , RESID 101-000-241-000 $.39
tYY�1,TCrION AM PLAN c''3F.G:Y
$150.69
Q`
D Q MIS PRE -P.P;LD.T'E'ES
$0400
01-C 16 2003 , :�'Mu"Tr r"S x�ta� 11 Now
WSO.69
CI YY OF LA QUINTA
FINANCE DEPT..
RECEIPT
DATE /!
BY , /
DATE FI AL
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 8 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 8 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 v
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final A
Gas Piping
PLUM NG APPROVAL
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
Fbdtires
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)