0108-088 (PAT)LICENSED CONTRACTOR DECLARATION
U) I hereby affirm under penalty of perjury that I am licensed under provisions of
1— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
N W • ..-Pre4essionals Code, and my License is in full force and effect.
O 5 M License # Lic. Class Exp. Date
r` d � 480
34 W1
p kT?
o Z spate? �� Signature of Contractor• k
CD 0-
J U OWNER -BUILDER DECLARATION
W W I hereby affirm under. penalty of perjury that I am exempt from the Contractor's
~ d 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). ,
M () I am exempt under Section B&P.C. for this reason
N Date Signature of Owner
OC
CL Q WORKER'S COMPENSATION DECLARATION
p Z Cr I hereby affirm under penalty of perjury one of the following declarations:
Lo <O () I have and will maintain a certificate of consent to self insure for workers'
X LLI �= compensation, as provided for by Section 3700 of the Labor Code, for the
p J Q performance of the work for which this.permit is issued.
CIO Q U (gid 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
dpermit is issued. My workers' compensation insurance carrier & policy no. are:
CI)It Z Carrier Policy Na.
aoo O EMPT
J(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
'6 subject to the workers' compensation previsions of Se 3IL 700 the Labor
. Code, 1 s all forthwith comply w lh hos3 pprrovi i • sr
�i
Date: Y—4a-11t Applicant� �
Warning: Failure to secure Workers' Compe sation 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
construction, and hereby authorize represeUt, t is City to enter upon
the above-mentioned property • r inspection
$Pgnature (Owner/Agent) t Date
BUILDING PERMIT PERMITN ;•,
J
DATE VALUATION LOT TRACT
i/ �I
JOB SITE
APN
ADDRESS �(�g -�a� �•t;�,�p,�y
41'•750 �ryJ.LVeAC
OWNER
CONTRACTOR/DESIGNER/EN (NEER
GODWIN Oa. NT1 1'R.UrIY' MIT COMI'My
47.750 UMI.'C
68^229 EML ROAD-
.%.AQUINTA CA 92233
CAT/�k%ry,'~w.pl��a^�G%[y.Af� rry �..�.[yp�92.2,34
Q60)3.24-7643
USE OF PERMIT
PA710
390 SQ. FT. LAf"I ME PATIO COVER PM APPRO'VZD PLA
Pt?Ri:i PATIO 320.00 3F
ES"TRA&M COST OF COAMMUCTION
5054.00
PI'M0HWK FFS .0W-139.318 U2.65
eMS'I••bEi91C' ION FEE 801-000-418--000 $R1 a0
,7R..0'901%10T l't:N{ RX, - P�.&OPI r 101.,000.241-000 8;3!
a AUG 1 o 2001 ,' I
I✓L:PT
RUB- °��"alp£,fit"���°�`�.'��'�nd6R-A�:►�1���
MUMP FEES DUE NOW
RECEIPT }
DATES f
BY t
DATE FINALED INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Duds
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
0. K. to Wrap
Framing 8/Z��,� �.�
F.A.U.
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
/ / S�
Final IMA;
BLOCKWAI PROVALS
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
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)
COMMENTS:
U•r/t �`/� -2
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