0011-136 (PAT)U)
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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 r Exp. Date
a310674 C61'06/30/2(
� 06/3012(
.Date /C — 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: t
( ) 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.
�( ap 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 -'to become subject- to the
workers' compensation laws of California, and agree hat if I should become
subject to the workers' compensatio�fpr�visi r1�Pof�S ction 3700 of the Labor
Code, I s all fo hwith comply with tGto ` provisions.;
Rate: <� Applicant 4Y
Warning: allure 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 anqrstate that the above information is
correct. I agree to comply with.all City, a , lState �aws relating to the building
construction, and hereby authorize repr9sentativ4s of this City to enter upon
the above-mentioned propeY4 for inspegtion purposes.
Signature (Owner/Agent) �- Date a�
MEMO, W.{)f.Y
+36,554J M1i'`1;f DAHMMRA
LA QjJ..DnA,
USE OF PERMIT
ML.gROSS
C(i"ORAnON'
�v ?tet 13 T�'.F�.L A 07,
CA. 925.; P11MRS.1AE CA 92509
1 (909)782-23&n (131.* 61.-52
PATIO MCInSURZ - iC80 V49pt7P '
14X14@196a>;'QIVY.
V1,EC RICA1, • 2 LIGHTS; 2 Mi't"KE.% x OUTLETS
f'i7RCHIPAVO 196. Do OF
���.q 1�A�1� e4k�°. C -On 01F CrO:�+i91kriCR`k�'N
1'1" C],�ECK .SEE 101-000-439-318 $3110
cams-a"`Sf:un—l4D1
:1'E•ROEd0 MOTION IFE'E • IiEISID 101.000.24.1.000 8.$Q
Tr1X 11RIC LFM 101- 00.420-0010 V9.0
SUP-'1'O'TA,i".ORI1` ICTIC31'SAMi'SPLAN L -MCK
71=1 ,"G'.'RE-Pt? W I 1r.x
RECEIPT DATE BY / ✓' DATE FINALED I INSPECTOR
2160M •.
$109.10
So=
$109.10
BUILDING PERMIT
PERMIT#
WN
DATE
VALUATION LOT
TRACT
JOB SITE
APN
ADDRESS
iL "60 ,AVR" .A . IRIPP.f!
OWNER
CONTRACTOR/DESIGNER/ENGINEER
MEMO, W.{)f.Y
+36,554J M1i'`1;f DAHMMRA
LA QjJ..DnA,
USE OF PERMIT
ML.gROSS
C(i"ORAnON'
�v ?tet 13 T�'.F�.L A 07,
CA. 925.; P11MRS.1AE CA 92509
1 (909)782-23&n (131.* 61.-52
PATIO MCInSURZ - iC80 V49pt7P '
14X14@196a>;'QIVY.
V1,EC RICA1, • 2 LIGHTS; 2 Mi't"KE.% x OUTLETS
f'i7RCHIPAVO 196. Do OF
���.q 1�A�1� e4k�°. C -On 01F CrO:�+i91kriCR`k�'N
1'1" C],�ECK .SEE 101-000-439-318 $3110
cams-a"`Sf:un—l4D1
:1'E•ROEd0 MOTION IFE'E • IiEISID 101.000.24.1.000 8.$Q
Tr1X 11RIC LFM 101- 00.420-0010 V9.0
SUP-'1'O'TA,i".ORI1` ICTIC31'SAMi'SPLAN L -MCK
71=1 ,"G'.'RE-Pt? W I 1r.x
RECEIPT DATE BY / ✓' DATE FINALED I INSPECTOR
2160M •.
$109.10
So=
$109.10
Waste Lines
INSPECTION RECORD
4.7
I
7
OPERATION
DATE
INSPECTOR
OPERATION
Sewer Lateral
DATE
INSPECTOR
Encapsulation
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
�Underground.Ducts
,
Forms & Footings
Ducts.-
Slab Grade
Re{um 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 & CorStrit'i: -'4' '
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
Steel
POOLS-SPAS.
i,
+
Set Backs., .
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
a
Underground Electric
t
Underground Plbg. Test
Final
Gas PAping
:S
PLUMBING APPROVALS
Gas Test
Electric Firial
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
Final
COMMENTS:
Final
I ELECTRICAL APPROVALS
TemD. Power Pole
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)