0303-273 (CGAR)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
N W Professionals Code, and my License is in full force and effect.
O C) License # Lic. Class Exp. Date
W 306566 IiIC/28103
r
6 Z r- Date,--- Signature of Contractor
(O L /
Ji. -
C) OWNER -BUILDER DECLARATION
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ U) 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).
ce) () I am exempt under Section B&P.C. for this reason
LO
N Date Signature of Owner
ON
O
U Q 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.
('�J) 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 FUND Policy No. 1:176131-2002
(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 subjectlto the
workers' compensation laws of California, and agree that.if I shouldecome
subject to the workers' compensation provisions'of Section 370`b of t e Labor
Code, I shall forthwith comply with those provisions.
/Date:.] Applicant
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 hit .
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 comply with all City, and State laws relating ;o the building
construction, and hereby authorize representatives of this"Cityto enter upon
the above-mentioned property forinspection purposes.
Signature (Ower/Agent) ' Date
BUILDING PERMIT PERMIT
2M
DATE VALUATION V".20 LOT TRACT
J.
JOB SITE
ADDRESS 47 -OAU WAS7�MMON MIM
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
LPP INC"
COI.Itd J MC DERMO'Y DUC I)PRMOTP M4T
PO BOX 14447
Po BOX163
IIAI. l4 MERT CA 42260
PAI. M;�;HiZT CA 92261
(760)346.0745 CS1!! 6541
USE OF PERMIT
10 Sr' x i6' {JK[S. 100WMAl UUt,a NU I I Ni—LULot tta.a* l'KA'Al,.
(259: S.F.j
QA.P.AORIt7ARPORT 24592,00 3F
ESSIl1'M` ND COST OF CONS-!NUMION
KrQ.8O3.2l�
i'h`F Mri',b% R 9UMMARY
CONSTRUCTION FEE 101.000.418.000 $419.00
PIAN CHIrl.:K M 101-000-439-316 431 cm
UTROI90 MOTION FU - COMM 100-000.241.000 $10.67
ART IN PPI L.IC PLACVS - COtAt 270-000-445-000 =754.02
MEL-370TAL CC7r1.�irR=014 A14D PLAN CIMCK
M.".
LESS PM -PAID I''Z..9
Saw
TOTAL PEitWr MS DUE NOW
5999.99
RECEIPT
DATE.BY
DATE F L D
OR
:E
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7P
iI
ILI]
F�P_
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
644WOr
Final
Final
aPOOLS
BLOCKWALL APPROVA S
- 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
OX 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 1
Sub Panels
Exterior Receptacles .
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
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