0004-216 (PAT)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
CO Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
cel WProfessionals Code, and my License is in full force and effect.
C � License #" Lie. Glass Exp. Date
LLJ
c Z
/ate �' = Signature of Contractor `
0 rr r
J U OWNER -BUILDER DECLARATION
Ha I hereby affirm under penalty of perjury that 1 am exempt from the Contractor's
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).
C•`) () I am exempt under Section , B&P.C: for this reason
111.
O N Date. Signature of Owner
a Q WORKER'S COMPENSATION DECLARATION
o Z I hereby affirm under penalty of perjury one of the following declarations:
Lo HCC
O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W L= compensation, as provided for by Section 3700 of the Labor Code, for the
mJ Q performance of the work for which this permit is issued.
Q h,have and will maintain workers' compensation insurance, as required by
p U Q •Section 3700 of the Labor Code, for the performance of the work for which this
a; � Z permit is issued. My workers' compensation insurance carrier & policy no: are:
CI
Sj Camer STATF FUND Policy No.
g (This section" need not be completed if the permit valuation is for $100.00 or less).
( ) I cAiy 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
wor ers' compensation laws of California, and agree that if I should become
�syl5ject to the workers' compensat' provisions of Section 3700 of the Labor
ode, I shall forthwith comply with't se provisions.
Date: Applicant,;
a t
Warning: Failure to secure Workers' Compensati n coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $1-00,000, 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 oYBuilding 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.
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 representatives of this City to enter upon
th above-mentioned property for Inspection purposes. /
ignature (Owner/Agent) �'�� r'A` y'� Date
q -n -o'`' BUILDING PERMIT PERMIT#
DATE VALUATION LOTTRACT
' $9,576.00
JOB SITE
APN
ADDRESS 4.5 -CM M7RDRClOK CMCZ F
OWNER
CONTRACTOR/.DESIGNER/EN (NEER
AL1.)A 3TARDER
TA ?TS% CONSS'C UC M014 COWIPa7'Y'
45-605 )O1:.tIRMOOK t'1RCILE
123-2815 OgC'•' jo L)F
LA QUINTA C k 92253
DF3EVTHYr8PRDTCA CA 92240
(619)329-0157 M. 110 06061
USE OF PERMIT
.VATIC)
c
720 S.P ALt7Mli. Woart A'rTICE PATIO COVER QC -B0 ER -2621P)• PU
APPROVED PLA149 ONLY
PO1CCMIATY) ili).OG SF
f�
EXS'.tMATED COST OF CONSTRU TON
9,576.W
PF,R1rr F +' .RIMMA)RY
P AN CHFCK-AE 101.000.439-3116 b1741it9
CONS't RUCTION FEE 101-000-418-000 $i 17.00
STRONO MOTION FEE - RES117 101.000.241.000 S.96
b
8T)B-1rffA1., COWLfkUC°l` 0N' AN1) *PIAW_1TFCK
$1194.01
12-90 PRF-PATt71:Tt 9V
`f0.00
TOTAA, ITUU ATT+ITS T)ix7�:1VC'W
RECEIPT
DATE
DATE FINALED
INSPECTOR
(ABY;
INSPECTIOti RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
RetVm 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 tidm0I Kill
BL OCKWALL 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
PLUMBNG 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 Voftage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
CITY OF LA QUINTA
a RE -INSPECTION FEE OF 130 BUILDING $SAFETY DEPT.
WILL BE CHARGED IF TM ArrmvcwNLDATS��.2
rflOVED ,� PoS'CD ,��C7o�e e Fa e
PIANS AND 108 CA ONSTRUC 1ON m /es R • P. ll.�wAE�
THE SITE FOR A SCHEDULED ys-jos J�E.��eooF
INSPECTION. � 2 S
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COrYT�:ci op : T.4�.at �S.e' caws r, Cu.
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