0004-213 (PAT)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 f ce a.ii effect. '
'License #, Lic. Class , p. Date
s 55£N4tr;�` -i i 1213]12(
ate Signature of Contra�c o,
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason: V
( ) 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).
( ) 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 STATE FUND Policy No. T34-0002336
(This section need not be completed if
() I certify that in the performance,
I shall not employ any person in an,
workers' comp,e�nsation laws of Calif
subject toe workers' compensa iol
{.Code, I s�al`fArth ith comply with.thl
Date: Applicant
permit valuation is for $100:00 or less).
e WOFUer)which this is issued,
nner/so as to become�ubiect to the
gree that ,if should become
of -Section 3700of the Labor
` .Parning: Failure to secure Wk ' Co�pensation'`co/verage is unlawful and
shall subject an employer to criminal pena ties and ciyitfines 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 apcatione nd state that the above information is
correct. I agree to comply wit all City, and State laws relating to the building
/. it
construction, and hereby audthorize• represen tatiVes• of this City to t upon
thlabove-mentioned property/for inspeeti n.ji r"poses.
Vignature (Owner/Agent), " f �f f/ Date
s Y !
0
PERMIT #
u BUILDING PERMIT
���
DATE VALUATION LOT TRACT
04/2012(K S4AW1.10
JOB SITE
APN
ADDRESS 47-785 SIMIAC
4
OWNER
CONTRACTOR / DESIGNER / ENGINEER
,
Ora
m�rlw r
B1,3�Co1 I)e DDC
4`i -7R5 RIMAC
39867 C CI=COVE
1..A QuM..A. CA 92253
PALM MERT CA 92211
(760)345-4.116 CBIX
USE OF PERMIT
P 110
PATIO COVER 367 SQ. FT. WOOD STRUCTURE
POROWPE4TIO 367,94 3F
ESSTE4Cdsl,= COW OF coff9mucrION
4A1,10
PFlow FEE S'IU11MA71. Y
FILM CHWK. FEE 101.000-439-31€3 $44.39
CONSTRUCTION FEE 101-000-419-000 snoo
STRO O MOTION KM - RESID 101.000.241-000 tso
R
i�
i
SUB •.I Oi.`AL CO1'3'MUC,IiCN AWD PLAN CM"."X
4, .$119.30
b, PRE -P. Ails FM
$0.00
AYTAT, P.MMT-11' F S P E NOW
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RECEIPT
DATE
fBY y 1!
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
BLOCKWALL APPROVALS
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 Y— 3 -0,0
Utility Notice (Perm)
COMMENTS: