0206-045 (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 force and effect..
License # Lic. CI s� E p-[ ate
.bf 0484 B 3 �� �1w IIZ�
Date�(f
'` �- Signature of Contract r
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License 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 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,
r
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:
Cartier STATE FUND Policy No. 2 9--101 51M '
(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 P�Iif ia, and agree `tL t if I should become
subject to the workers' compensation p visions o�Secfibn 3700 of the Labor
Code, I shall forthwith comply with N:,se roVision
Date: / fug Applicant r
Warning: Failure to secure I er,94ompensation 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.t
I certify that I have read this application and state that the above information is
correct. I agree to comply vy.ith.,all City, and State laws relating to the building
construction, and hereby author e`representative,oflthis City to enter upon
the above-mentioned property)or In pectipurp ses. f
Signature (Owner/Age tn) on
` ��—" � Date.191& 1/1-
BUILDING PERMIT PERM T#
DATE VALUATION LOT
JOB SITE
ADDRESS '»{ a�'v�%���%i� Cnbe����i�!�+ APN
OWNER LAI I CONTRACTOR/DESIGNER/EN
B X3 :j.+ONTE aS
USE OF PERMIT
PATIO
WA1.. I ATiON NOI ER -201P
POWWATIO
I
TRACT
'74691
THCAJ&*M PAWL' CA. 92276
(760)2'75-6017 CBLff 31 Oro
MyrJUX)ILID COST OF CONSTRITMON
PL"m Cl'il ct VEF 101 -NO-434.31 i td49.�3
CONSTRUCTION, CTION, lqf g 101-000-4188 000 $63.00
S'iM913 MOTIM11 EF - MM '101? -000-241--000 910
a 'U-
c ITY01H.A�u1nlr,�
EDEpr ;
'; &;TOTAL gala=1a<c:1.�ON W13 PLNis CHECK
c ms
I'MAT. PERWY DUE NOW
RECEIPT DATE 3DATE FINALED IN
1
$104.45
$0.00
INSPECTION RECORD
OPERATION
DATE
INSPECTOR OPERATION
DATE
INSPECTOR
BUILDING APPROVALS Z MECHANICAL APPROVALS
Set BacksUnderground Ducts
Forms & Footings Ducts
Slab Grade Return Air
Steel Combustion Air
Roof Deck Exhaust Fans
O.K. to Wrap j F.A.U.
Framing Compressor
Insulation M AA Vents
Fireplace P.L. ; Grills
Fireplace T.O. Fans & Controls
Party Wall Insulation Condensate Lines
Party Wall Firewall
Exterior Lath i
Drywall - Int. Lath
Final
Final 2
POOLS - SPAS
B OCKWALL 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)