0205-184 (PAT)LICENSED CONTRACTOR DECLARATION
U - I,hereby affirm, under penalty of perjury that I am licensed under provisions of
H ,Chapter,9 (commencing with Section 7000) of Division 3 of the Business and
cel W Professionals Code, and my License is in full force and effect.
O =) /Ych
License # Lic. Class Exp. Date
LO
26(M84 B r��"'�
� t�NM
oZ t— ,/Date 124" 1y 107,Signature of Contractor
m O. i`
Ji__
CD OWNER -BUILDER DEC ARATION
HLu I hereby affirm under penalty of perjury that I am exempt from the Contractor's
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
rn
a Q WORKER'S•.COMPENSATION DECLARATION
C) 2 Z I hereby affirm under penalty of perjury one of the following declarations:
�. If -insure for workers'
p () 1 have and will maintain a certificate of consent to se
X W U 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 U 1 have and will maintain workers' compensation insurance, as required by
Q U Q Section 3700 of the Labor Code, for the performance of the work for which this
11 rn permit is issued. My workers' compensation insurance carrier & policy no. are:.
It z Carrier S3`.s3TE FIMD Policy No. 2291-020M.05
r, 0
J
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) I certify that in the performance of thework for which this permit is issued,
I shall not "employ any person in any manPter^ �sso as to become sd6jbct to the
workers' compensation laws of California, and agree that if I sKould become
subject to the workers' compensation provisions,)of Section 370X0rrrof'the Labor
3 Code, I shall forthwith comply with those�provisi6ns""
z4//Date: _L2212.2-5-11,2- Applicant I /A
�-
`` Warning: Failure to secure Worl ers' Compensation coverage is unlawful and
-;" shall subject an employer to criminal,pepalties 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 state that the above information is
• correct. I agree to comply with -all -City, and State laws relating to the building
construction, and herebyjauthorize representatives D;this City to enter upon
the, above-mentioned property for 'nspecti n pu rp, ses.
.' Signature (Owner/Agent) ` Date "5- 1.2,V to -z..
DATE
BUILDONG PERMIT
\/GI I IATIMI I nT
9WNW
97,31.51*
PERMIT # 1
0ti05-1$4 TRACT '
JOB SITE
ADDRESS `45-4140 i:OTdDUlZC7OICLANE APN _
OWNER CONTRACTOR / DESIGNER / EN (NEER
TOM 1e. C"ELR M, R PKJLM1.M. C°C)NSITi.UC4110N,
5 -44-0 COLDBROOK 1:,AW 4691 ' � :..1. MA GFJ ROAD
Lr?, ill 1;1` CA 9:1233 HOTTSAWD PAUAS E.:A 92276
rr;0)25-dti27 C,1`i>1QYs
USE OF PERMIT
T IM0
Ps✓yRICI-PRATIO,
'Pits COVER
o.firtSI
x /J.
ESMIAIM) C057 OF COPOURUCTION
PEr
C(:s'taS'!'td,UC:Ta'.ON krEZ 101-•00"18-000
S T fONQ4 LIO'1'IC-1411 10.7 a,00 l 241 X000 V7�
z
I RECEIPT
LAN U_ 11
MAY 2 0 IIS`?%
WYOFLAQUINTA
l7lJB-°1OTAI� COJ,"i'G�.f.��UC1d0Fd AW) P•L-n MIT 1....iMCC -t:?.
- I.TOP P.aR-PAID:FSM
1XVIML _P100911 IrEll X811 D VIP. MW
DATE FINALED I INSPECTOR
$004*
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 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
'Drywall - Int. Lath
Final
Final
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
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:
�Stiy(� C,olc�b�roo�c LVN
Lca Q,,w . GA
chaas3
�4D
Atw"v t,,mc( l Pte-° COs -
A RE -INSPECTION FEE OF $30
WILL BE CHARGED IF THE APPROVED
PLANS.AND JOB CARD ARE NOT ON
THE SITE FOR A SCHEDULED
INSPECTION.
.NO EXCEPTIONS!
CITY OF LA QUINTA
BUILDING & SAFETY DEPT.
APPROVED
FOR CONSTRUCTION
DATE#av/ Z BY