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LICENSED CONTRACTOR DECLARATION
I- affirm under penalty of perjury that I am licensed Under provisions of
C72pt4 94commencing 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
691694 07/3V20i
)11
Cot , !�/� a Signatur . e of ContractorAQ443..._
OWNER. -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1, 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).
1, as owner ' of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
I am exempt under Sectio� 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 f&'by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
(Q� 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 Policy No...
"Ir 4 1141 F. -r I 191AW1 1 110
3
S I A IND �t -vt
(This section need not be completed ifthe permit valuation is for $100.00 or less).
I certify that in the performance of the w ork 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' . cbmpensation/provisions of Section'*3706-of'the Labor
Code, I shall forthwith comply with those provisions.
E(ate: Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subjectan employer to criminal penalties and civil fines Lipto $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 restri6tions get 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. A i ny 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
corre , ct. 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, inspection purpo§es.
i.Signature (Owner/Agent)
444ZC ate _42/_
PERMIT#
BUILDING PERMIT
DATE VALUATION $120."7.4t) LOT 10 TRACT 73995-15
To-BSITEI
ADDRESS 4�155 COLDEROOK LANE
OWNER
CONTRACTOR DESIGNER ENGINEER
INCORIONfEs COIZAR
"Ir",1101 HIOMRS C(0411%.P,
1282, W_ARROW HWY
1292 W. ARROW H.WY
UPLAND CA 4917S-5
UPWUND Q% 9A785
USE OF PERMIT
SNGLP FAWLY WELLINO
SFD- LOT 10, PLAN,M-R, - PERhET130113 NOT INCLUDE Y-kLt-.,, C WA1.1,
UP, KYUL, 7Y'le ItWOUCTION 014 PLA14 4JHWK FFE.VORI IL I'll X
ISSUMCE, QTZ SAN& PL AI -J 31'M
TIZAC' r GOTMU RUCTIC04 SF
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C)ARA,�MJCARI-10.11T %3.00 SF
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8SI.fA-'1'QTAJ, (70N8!T,UCTT0N` AND P! AN CHECK
L `SS PRF
f PAM FEE 13S
TOTAL DUR NOW'
IRECEIPT
IBY
I DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTIOR
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
cz - 3z
191
F.A.U.
Framing
^ — 5. 0)
01
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
Final
FU
POOLS -SPAS
BLOCKWALL
APPROVAL9
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
6 A/Z
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
(-IE66
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)