0106-183 (PAT)LO
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.---LICENSED yCONTRACTOR DECLARATION ;.
1`her6by-affirm under -,penalty of=perjury-that 1=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. Clas'_ l Exk p. Date
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50V7 B
Datek5+ ' ` � 3 `f , Signature of Contractor
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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 isnot intended or offered for
sale (Sec. 7044, Business & Professionals Code).
( ) 1, 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.'
(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
subject to the, workers' compensationp�ovisions,,of Section 3700 of the Labor
Codes I shall forthwith comply with th a provisions. —'
Dater I/, , .. j. APPlicant T AA;", I
Warning: Failure to secure Workers' Compens-Oon-eovecage is un
shall subject an employer to criminal penalties and civil fines up to $1
addition to the cost of compensation, damages as provided for in Se
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building a d Safet Li
for a permit subject to the conditions. and restrictions set forton his
application.
1. Each person upon whose behalf this application is made & each p rson a
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 subjectpermit 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 author ze representatives of this City to enter upon
the above-mentioned property fInspection, purposes.
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Signature (Owner/Agent)—t �i1'`1�� `�_ �.»-- Date
BUILDING° PERMIT-- PERMIT N.
DATE VALUATION LOT TRACT
06111.5/2W. M745M
JOB SITE
APN
ADDRESS
49-336 VIA.ARKNOSID
'
OWNER
CONTRACTOR DESIGNER /EN&NEER
WINDSIAOMd
BgAyLIGpCLyC/6V3. CVabJb
49^335 WAA1ti.EM- 040
68-211 ROAD
!AQt',?W'iiA CA 92253
C,MOORAT,; CA 922.34
(760),3214M 033110 3106
,
USE OF PERMIT
432 SO? .?iLIAILA' VOOD PATIO COM ricuo fiFA„2621 P)
CO1rALd t, f'3 S FOR WORK BEGUN 'WITHOUT BUlMl'1` O I'1; RI MIT,
PORCHW TIO 432,00 SIP
'&.�iA13V COU OF %'ONUUC OX
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JUN 1 5 2001
CITY OF LA OU1NTA
FINANCE DEPT
01ria-TOTAL ('01.M1'}a.CY%".1`A'O .F' M PIM MECK
$215:22
1X483 PREXPAM MM 3
100100
TOTA111PERWY7 X-1110 D119 NOW
122
RECEIPT
DATE• BY
a
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DATE FINALED
INSPECTOR
,/' 4
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 Wali Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath -
Final / ��
BLOCKWALf_ APPROVALS
Final
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. 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: