0004-210 (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 # /3).
r E p Date
699690 DD � r%�' f 12/31/'2(
Zr
Date`Q��"" „signature of Cont�k'
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
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 FU14D Policy No. 373 --►9-0006434
(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
i!deJslqqll
bject to the workers' compensation` provisions of Secti n 3700 of the Labor
forthwith comply with those p ,isions.
Warning: Failure to secure Workers' Compep'sation coverage is unlawful&nd
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
correct. I agree to comply1with all City, and State laws relating to the building
construction, and herebyl authorize representatives of this City to enter upon
the • ove-mentioned pr9pp�erty fof,inspectioA purposes.
nature (Ownejdnfi)' t Date`"f
e
' PERMIT #
BUILDING PERMIT
DATE VALUATION LOT W04-210 TRACT
SIA35AO
JOB SITE APN
ADDRESS 79- DEWR, STIREA:M - -
OWNER CONTRACTOR / DES GN N&GINEER
3AM'r BOW&RS ±3UNLAND SCRs EN & AVM.W(; CO.
79-250 DEXERT STREAM 46080 CALHOW FIM -r
LA, Q INTA. CA 92253 I23Di0 CA 42201
(760)347-0592 CDT-* 4996
USE OF PERMIT
PATIO
PA'PIO COVE R-ALUMAWOOD PATIO COVER. 138 SQ. FT. (IC80 2621 P)
PORCWPA.TIO
III&Do 8F
MS'MUTIK'D COST OF CQN�'A'.F2T)'C 110AN A,MAO
YV,RWf FEE SUATMA Y
PLAN CF3Wk FEE 101 -000-439-318 827.95
CONSTRUCTION FEE 101-000-t18-000 $43.00
5TRONO MOTION FEE - IRESID 1111-0010-241-000 3.50
SUE -TOTAL CONST t)(MON AND FLAW CTM= %71.45
LTMS PRE -PAW RMS f3,f)0
PT IDATE
DATE FINALED I 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 Vottage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: