9905-149 (BLDG)LICENSED CONTRACTOR DECLARATION
1 '?yereby 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
C -t tai 1q,' 19!
Daatte tj— /0 " `�YSignature of Contractor
i' OWNER -BUILDER DECLARATION
1•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).
( .) I, 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 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.
4�t."�'A.'!'� trt1NJ t►-3�r-.`�U-11(1(1" �r�`�
(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 which this permit is issued,
I shall not employ any person in any manner so as to becol a subject to the
workers' compensation laws of California, and agree that�f I should become
subjeci to the workers' compensation provisions of Se�tion 3700 of the Labor
CoBe, I shall forthwith comply with�those pr visions ---
_..a–
l✓
Warning: Failure to secure Workers' Compensati 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 application and
correct. I agree to comply with all CiVnd
construction, and hereby authorize represe
the above-mentioned property for inspection
Signature (Owner/Agent). ` ,
the atiove information is
relating to the building
A; City to enter upon
Date
BUILDING PERMIT PERMIT#
99(►5-1i9
DATE 0511 WI" VALUATION 54,495.40 LOT TRACT
JOB SITE
ADDRESS 7"72 $1A COUR ' APN
�+
OWNER CONTRACTOR / DESIGNER / ENGINEER
Ki'I".114 & MICHE'LE, GIBSON. A` LAS At1^N[NO CUMPANY
78672 .SIFNA Cr 75411 K-LIANIS ROAD
LA Qa JIWA CA. 42253 PALM SPRINGS GA 92264
(76(Y)317-9466 CM.4 1825
USE OF PERMIT
li}tiNRIL1L BUILFANG
338 S.F. t1i.C1`1MUM SOt.M PATIO C''%IVER (ICB0 020'If )
FORUir 171170
318.00 Sr,
E.NTIAIAIIED COST 0F.CONISTRUCTION 4,495.40
PLAN CHECK 'Fr- 101.000.439-318 V6 so
C; i'NS i? [ YC;° (ON h f i 914)(110-0 8-i1i)(i
'OPTIZ,0arc, MOT1014 Fl,T - RESxn 101-000-2141-000 5.50
St.TWIMAl, C ONS'!°RIX110N AND PLAN C TAWCK S119.30
LESS PRE-P.ULDPEES so W,
r
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RECEIPT DATE By ; �" DATE FINALED INSPECTOR
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 & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
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)
r/. A S
AUTHORIZED DEALER
WNING FOR ALU
AND ALCAN PRODUCCTST§
COMPANY LIC. NO. 376238
Owner's'. (�e�+h bl�Che-k2. C-,,6son _
e r-0-FACCEPTED
CITOV
Co► Os-� 10NA �LY
FOB CONS-fi:" lJC, ION
i' "�'(� IIvST►�. ,MON AS PER
. AND ALL APPUC6 LE CODES
BY
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'Pro Posed. poria
2 I 15' co ver
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754 Williams Road/Palm Springs /California 92264/(619) 327-8466