0311-098 (BLCK)LICENSED CONTRACTOR DECLARATION
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
04 W Professionals Code, and my License is in full force and effect.
o M License # - - Lic. Class Exp. Date
LLJ�Qv7
ti84d� - C'29 04/30M
Z r_ Date -Signature of Contractor
CSO 0
J U , ;' 9WNER:13UILDER DECLARATION
W WWi hereby affirm -under penalty of perjury that I am exempt from the Contractor's
CL
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 exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
coO I am exempt under Section B&P.C. for this reason
N Date Signature of Owner
ON
rn
Q WORKER'S COMPENSATION DECLARATION
C) � I hereby affirm under penalty of perjury one of the following declarations:
Lo P O O 1 have and will maintain a certificate of consent to self -insure for workers'
X W Y= compensation, as provided for by Section 3700 of the Labor Code, for the
m� Q performance of the work'for which this permit is issued.
Q () ( ) I have and will maintain workers' compensation insurance, as required by
O O Q Section 3700 of 'the Labor Code, for the performance of the work for which this
d H permit is issued. My workers' compensation insurance carrier & policy no. are:
z Carrier co 5 �TATL+ CKIMPTEMAT) , .Policy No. 2x403007837
�Q 1. • 1"
.
g (This section need not be completed if the permit valuation is for $100,00 or less).
( ) Icertify that inihe 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'..compensatiori laws of California, and agree that if I should become
3 ubjectto the workers',compensation-provisions of Section 3700 of the Labor
Code,,.I,a- all fortl5wiih comply with ftos provisions.
il Date -� Applicant
i
'Warning: Failure to secure Workers' Compensation coverage is unlawful and
` shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth 'on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed'under or pursuant to
any permit issued as a result of this applicatofi' agrees to, & shall, indemnify
& hold harmless the City of La Quints; its office�p;/agents and employees.
2. Any permit issued as a result'of this application becomes null and void if
work is not commence (thin 180 days -from date of issuance of such
permit, or cessation (work for 180 days will subject permit to cancellation.
I certify that I�have read this application and state that-t!16above information is _
correct. I agree to comply with all'City, antrite laws relating to the building
construction, and hereby authorizer sentatives of this City to enter upon
the above-mentioned prop rrty.•fo, ' pection purposes.
/ Signature. (Owner/Agent) J J Date
BUILDING PERMIT PERMITX
DATE VALUATION LOT TRACT
11/1XIM 3"9.$RO.iICi
JOB SITE
APN
ADDRESS 53,70 AVE-INMA COR1724
OWNER
CONTRACTOR! DESIGNER / EN (NEER
M/ME POMA'RLE.AU
TIZAWK ,PFXSAN I MMOM, Y
53 -?0.S AVEN WA Ct}:1MY,
7404) EL COitTFZ WAY
LAQUINTA CA 92253
PALMDESEFtF, CA 92260
(760)346.0892 (MLk
USE OF PERMIT
c3h2L �'IiJlLDI lG
64 LIP 2' RETAIAIINO WITH 6' QARl:FN WALL ALONO NORTH PIL•. is
LF 1140 RETADRINOWITH 6' 0ARDK14 WALLALOW SOUTH. PIL ALL
PER CITY STANDARD. 2001 CDC,
6 FT, WAIL I.L f 36.00 LF
11:ST MA71M fel 5—f CST CON:V%'Y UC TIOIgT
�,4(1f1,4►O
1'la:R'Etl n'YEt s>[TmwRy
COWRTRUC.:'PFt: N FEtE: 10) -OOO-418.000 56100
D
�
2003
OF LA QU1WYA
CI�ITiNICEO EPT.
T
fr'11Y3-`1't7TA7:: (]N PT�;YIt'`7`toAT A14D P1 AN Clikf'K
$63,00
.T.Y.9S PRE -RAM VERS
$0.00
i'OyA.d, PF -R r'J;'EI:a S UILl:!). T!T)w
RECEIPT
DATE
BY t/
DATE FINALED
INSPE—WOR
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.XU.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grids
Fireplace T.O.
Fans & Controls
Party Wali Insulation
Condensate Lines
Party Wali Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam .1t -o
Approval to Cover
(.
Equipment Location
12
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)