0108-183 (PAT)N_ U)
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' LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing 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
Date Signature of Contractor
' OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I,am exempt from the Contractor's
L'cense Law for the following reason:
() 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 theproperty, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
( ) I am exempt under Section B&P for this reaso
Date —Signature of Owner i
-• -r �y"^ WORKERS COMPENSATION E ARATION
VA!
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:
Cartier Policy No.
(This section need not be completed if the permit valuation is for $100.00 or less).
I certify that in the performance of the work for whiob this permit is issued,
I shall not employ any person in any manner Io s to become subject to the
workers' compensation laws o alifornia, an a•ree {{{ at if I should become
subject to the workers' compel Cation provisos y f S tio•p 3700 of the Labor
Code, kshg forthwjth comply."ith tl o�e,proj . ionp.
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 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 applicati and s ate that the above information is
correct. I agree to comply with all Ci tate laws relating to the building
construction, and hereby. horize r p as atives of this City to enter upon
the above-mentioned pro fourposes.
1 Signature (Owner/Agent) Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
JOB SITE
N
ADDRESS
OWNER;. ,.'
CONTRACTOR / DESIGNER / EN (NEER
43 4613 MONA 00I.Wr
T.& QYiJWA CA 92253
USE OF PERMIT
PATMr
476 aPA3..1iMPx`b'It;,013 PATIO 03VER(1CB09202sP)
Y+C. RC ]P TIO 426.100 3F
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CONSTRUCTION FRX 101 -WO -418-000 �2;1.t80
:3rROM MOTION VU v REMP 101-000-241-000 S47
p Ma-. 'T.�,. ' Fff,RUC:I'IORAND PUN* Ck-iEM
$134.22
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$0,00
AUG 16 2001 Ax, PY"rrrKE6 DUR
9134=
CITY OF LA QUINTA
FINANCE DEPT.
RECEIPT
DATE z/ Y
Y
DATE FINALED
INSPECTOR
.. W 1
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slali Grade
Return Air
St `I
Combustion Air
Rodf Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation v
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
_
Final 0
BLOCKWAI APPROVALS
Final
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
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough iring
Low Altage Wiring
Fixtures
Main ice
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)