9907-576 (PAT)04
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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (cqmmencing with Section 7000) of Division 3 of the Business and
Profassiorials Code, and my License is in full force and effect.
License # Lic, Class Exp. Date
693694
`7
, k,
ate 3ignature of Contracto
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 Section B&P.C. for this reason
Date -1 -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 for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
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.
STATE MIL1,11141)
(This section need not be completed ifthe permit valuation -is for $100.00 or less).
I certify that in the performance of the work fo ' r Which this permit is issued,
I shall not employ any person in any manner so as to bec ome subject to the
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation4rovisions, of'Sectiop' 3700 f the Lab&
Code, I s all forth)hith comply with those provisions/
V�dte:
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Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines,ul5 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 hereby authorf�ie representativbs of this City to enter upon
the above-mentioned property, o inspection purp I ses.4
if V
ignature (Owner/Acient),A& �'�)W,,dAeZtOate
BUILDING PERMIT PERMI T#
DATE VALUATON
Z .1 Jfj7J.80 LOT. 4 TRACT
JOB SITE
ADDRESS 45,130 COLDBROOK LAN F,
APN
6W_040421
OWNER
CONTRACTOR / DESIGNER I ENGINEER
DIM 1-10MES C01111P.
INCO HOMES CORP.
1282 W. JMOWIHIGHWAY'
1282 W, ISIRROW HWY
URiAND CA 917 85
UPLAND
CA
91785
CR1,4.
3319
USE OF PERMIT
PORCIVi ATIO 11276.41W Sr
CON191111tLIUMN 11"F -E 101 -000 -41K -ow 's -A, 4�. 0 0
KAN (,MrTK PiR
SlAo'-1140 10'OTION F.W-3 - REMIT) 101-000,241,000
NA JB -70 I'All, C0114',S"TR UK` P 0 N1 AN D P!, AN C REV X.
M
LESS TIRE-PAIDrl LIE S,*
$D.00
VVIRNIff FE ES DUE, NOW
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
99!1
INSPECTION RECORD
OPEPATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
et Backs
Underground Ducts
Forms & Footings 1?2zi�P4 9:_
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 FireWa'll
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS -SPAS
BLOCKWALL APPROVALS
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
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)