0012-111 (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
NUJ Professionals Code, and my License is in full force and effect.
0 M Lice e # _ Lic. Class Exp. Date
Q' r; 69".00 M'D52D63 2.31!
o OZ r --Date Signature of Contractor✓
(O _ "
J U � OWNER -BUILDER DECLARATION'
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ tl 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 excl'usivelyAcontracting with licensed
contractors to construct the project (Sec. 70.44`' Business & Professionals
Code). 1 e
�
O I am exempt under Section B&P.C. for this reason'
N Date Signature of Owner `
N
d Z t'• WORKER'S COMPENSATION'DECLARATION'
QI hereby affirm under penalty of perjury one -of the following. declarations.
r �— O () 1 have and will maintain a certificate of consent to self insure for workers'
X W LL compensation, as provided for by Section 3700 of the Labor Code, for.the
mJ Q performance of the work for which this permit is issued.
Q () I have and will maintain workers' compensation insurance, as required by
O .0Q Sec ion 3700 of the Labor Code, for the performance of the work for which this
tl 0:I—;,, 1 permit is issued. My workers' compensation insurance carrier & policy no. are:
?'z :':'Carrier Policy No.
col O FUND
J
(This section need not be completed if the permit valuation is for. $100.00 or less).
O 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
sub'ect to the workers' compensation provisions of Section 700 of the Labor
3 de, 1� 21 forthwith comply WA -I. ose r-Vis'dos;='
ate: Applicant,.//
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 applicatoragrees 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 all City, and State laws relating to the building
constTction, and hereby authorize representatives of this City to enter upon
the ebove mentioned property for inspection poses.
5i nnature (Owner/Agent) �� 7 _ �' -"" N DateO'
4 T
BUILDING PERMIT PERMIT#
DATE VALUATION LOT' TRACT
1.2nM20C $16,I44M
JOB SITE
ADDRESS
45-725 CC)LIDPi ROK
JAPN
_
OWNER
CONTRACTOR/DESIGNER/ENGINEER
PAI3I:, & TWCE GIAWE
MILAM SCM>4 & AWMING W.
45=12.5 C -OC LUBROOK.
46Ma CALi HOUN MEET
I'A Q-UINTA. CA, 92253
Its DIO CA. 92231
(760)30-0592 C—B LIt 4996
USE OF PERMIT
Y>AMO
463 SQ. FT. ALUMAW0013 RATIO C is k t2 PIMA D MAN P11W. IC80 Y
2621P AT lAt':i; ED.
PORCI-YPAia(3 fi a, 00 OF
UMMUED C( Me OF C(
6,144kO
PLAN C -BE K,1EE 1011-000-479-318 S.S&SO
t„"ONS'i' UC:'EION FETE Sol -00"18-000 P90.40
a''D'lXANG i+u1C:►'C3C? 4 M • 1MID 101-000-24-1-000 �,b1
X]h TMAL i'ON iRWMN AIR) PL.kW CMY,
$149.11
)ZO PRE-PIAMME1.1
$0.00
TOULYERWIT-FEMS DUE MOW
$149,13
RECEIPT
DATE-
ZY`
DATE FINALED
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
Final _23 (-of ' (_
BLOCKWALL APPROVALS
Final
POOLS - SPAS
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 (Perm)