0012-114 (BLCK)LICENSED CONTRACTOR DECLARATION
U) I hereby affirm under penalty of perjury that I am licensed under provisions of
I— 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 =) ch Lic nse # Lic. Class Exp. Date
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Z r a/ ate P� 111 �� Signature of Contractor
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C) OWNER -BUILDER DECLARATION
W W r— I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ U) 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).
cr) () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
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WORKER'S COMPENSATION DECLARATION
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2 Z I hereby affirm under penalty of perjury one of the following declarations:
U-) H O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W compensation, as provided for by Section 3700 of the Labor Code, for the
0J Q pert! mance of the work for which this permit is issued.
Q U ( I have and will maintain workers' compensation insurance, as required by
O 0 Q SeWon 3700 of the Labor Code, for the performance of the work for which this
H permit is issued. My workers' compensation insurance carrier & policy no. are:
't Z --Carrier Policy No.
co 5 ZWITH UISURANCE ZA4206M
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(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 become subject to the
workers' compensation laws of California, and agree that if I should become
Subj ci to the workers' compensation provisions of Section 3700 of the Labor
CO e,
DaI s all orthwith comply with those provisidns.
Rate: 11 �" , IJ Applicant . to le • I l if 121 PL,(,
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his ,
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
• correct`. I agree to comply with all City, and State laws relating to the building
conV.�uction, and hereby authorize representatives of this City to enter upon
the�above-mentioned property for inspection purposes. I
Signature (Owner/Agent) I ' frt` hlll 'i'U;1►/ Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 0012-114 TRACT
12/13MX t,t4(i( m
JOB SITE
APN
ADDRESS 79-031 MM IFAd0 J."S 60.
OWNER
CONTRACTOR/DESIGNER/ENGINEER -
Tww COIqa'fCtl. mou CO.
'I� CO.
7$-)20 CALLE:EM00 0206
78.120 C1 00206
1.,A QtMJ-fA CA 92253
1,.Ar :;1NTA CA 92253
(')'fitJ,�777•7611 MIA 3751
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USE PERMIT
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f 20 LF. frit 6 PP-VPERT Y L NE'+vlt'ALL - CITY SPECS.
6 FT. WALL 120,00 LF
:irSID"M COSI' OF C:OMMIC370N
11000.00
1.''ERM1 Fn 911MAIA12y
CONSTRUCTION M 101.000.4.118.000 s34.Da
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SUI:1 -IMAL CON�2x UM014 AND PI C'.FI1`� M
554.00
LMS PIM -PAID MMS
MOO
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IKRMT Y.I8 DUE N4aW'
4,043
DEC 13 280
.:IT ur LA Q041
RECEIPT
DATE) J JB1'
L
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
Patty 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)