0006-336 (AR)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 xp!DI e
447883 B. `� � �l rJ111121
Vj F
ate d4 a� V 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 Cade).
( ). I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
O 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:
( ) 1 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 . CLARF.3iDON NA' KY, Policy No. 02KYZ0004058
(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 Californian and a2gree�tQ"if I should become
subject to the workers' compensation proviSio9`�of,Secction 3700 of the Labor
ode, IlshalLfnrthwith comply with thosejpr(v ions. j
Date: Y4 2 e `xAPPlicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for 'a permitysubject to the conditions and restrictions. set forth on his
application.
•1.'Each person upon whose behalf this application is made & each person at
• whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify,
& hold harmless the City of La,Quinta, its officers, agents and employees.;
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation'.
I certify that I have read. this application and state that the above information.is
Correct. I agree to comply with.all City, and State//laws relating to the building
construction, and hereby authorize repr sentatiJes of this City to enter upon
the bone mentioned property for ' see tion pu(poses.
,ignature (Owner/Agents Date
V _ j BUILDING PERMIT PERMIT#
DATEVALUATION LOT$- TRACT
06flW20C $113".00
JOB SITE
ADDRESS 44''420 it'1A P=, �. SC1
s
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
'.I'PM G"1MOR014
SOUTH POWT C0$7MiJMO
44.420 VJA: DEISM
77.899 WOLF iu. 0102
LA QUDITA CA, .92253
PALL DFSU 1 CA 91260
(760)345-5521 CBL# 4320
USE OF PERMIT '
100 S.F.A120 f? N T12Y WAY CANOPY
f
r
'VALUATION 1,330,00 14
EWIMJd11.'1 ED COST OF CON U+u`ITON
PLAN CI� ECK FEE , 101.13110-439.318 $21,45
rF
CONST RUC Tiow FEE 101-000.418-000 $33.00
f
S'1 ROING MOTION FK9 t3 101-000.241-000 5,34
8UB-,dT°AL C°OAt i`RLiG°aTC)N AND PLAW CHECK
$54.95
L S PRE -PAID FEES
$0,00
1WAL 1'ERWi FEES DVE NOW
&M.95
le,
r 7
RECEIPT
DATE
BYE J�%
DATE FINALED
INSPECTOR
by
dU
I
-
J
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 Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
�7
t5
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
447883 B 3 oti 3l2(
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 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:
CartierCX.��itE1 ON AFATIC'� Policy No. 0IKRt1 A910b
(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.
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 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 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) Date .
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 0006-206 TRACT
(W30)2K n"I' m},Fits
JOB SITE
APN
ADDRESS
44-420 VISA 5?YL SCYL
- -
OWNER
CONTRACTOR / DESIGNER / ENGINEER
.+
MMWE C'A?�44�'Rl"? 7
�y
44-4?0VJA_DB12K_.)L
02
u tg1L3 ►WrA CSA. 92233
VA.<iYt TM�Mt' CA 92260
(760)W-5521��:i�l t 4320
USE OF PERMIT
:ta);: 3•rNMAL ADDr..1014
106 S.N. YINTRY lXi AY C.J�.'NOPY
VAL!lATiOW lis
X8':&MW D C ogir Off.'' CONY:['R.ii CTION
PF"Wr FEN, C:fM2i ARY
PJ AN C'flV?,K "M 301-000.4.39.3113
COA1:3'i`PUC"I'1014 FRIE 101-000-418-000
STRONG MOTION M - RES ID 101-000-241-000 $.so
RM- 3 �JI'AL C'03.3'STR aKMAOR AITD PLAN OEM
LESS PREOPM TIMM
$0,00
R'ar&L M TJ.7A:t, 3' S,' J'1 t; N JD ITE Y'i0 W
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
V
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
6.
Underground Ducts
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
�_ _may
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
_
POOLS - SPAS
BLOCKWALL
APPROVALS
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
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures -
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)