0203-420 (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. Class Exp. Date
748.571 a 04P30/20
Date Signature of Contractor
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 a em t under Section B&P.C. for this reason
�Date� Signature of Owner a ], ��.(';
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.
V) 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 , 1M SUM, Policy No.
0011M
(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' compensation provisions of Section "3700 of the Labor
Code, I Shall forthwith comply with those provisions s
Date: C ") Applicant Ve-� A/
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 t
correct. I agree to comply with all City, and State laws relating to the building &
construction, and.hereby authorize representatives of this City to enter upon,
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) '�7�':a.', XO Date •S
i f '; " s
BUILDING .PERMIT PERMIT# a
DATE VALUATION LOT -TRACT
JOB SITE;�KrQA APN
ADDRESS 640444.1-029 07 N .H yq7RJpL Xn
OWNER CONTRACTOR/DESIGNER/EN &NEER
MiCHAIRL V E'X-RAFF MCRAE. f`.XiM3�t�!CUMONNATIG .i;AOq
(909)849,,5911 031A
USE OF PERMIT
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540 SI.+ P.A. W 4:`:rf: V
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WRYNATARD CMT (W CONMUMVION
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STRONG MOTION FES - ZWJD 1014;W244 -0W $L72
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BY ** %+_ I DATE FINALED [INSPECTOR
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INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade z
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
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground PI . Test
Final I
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
"erior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
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EXISTING DWELLING
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13' 8" 15' O" 15' O" 15' O" 5' O"
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PROP05ED ALUMINUM
50LID PATIO COVER5 i
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/ CREAM
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FLOT FLAN
SCALE 1/8" = 1 FOOT
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PROPOSED ALUMINUM
LATTICE PATIO COVER
180 5F. / CREAM
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W KA F KIT KA F T E K
SLOPED 1/4" PER FOOT
3X8 HEADE'K /
EXISTING
DWELLING
I 3X3 POST
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SIDE ELEVATION,
SCALE: NTS