9701-097 (PAT)LICENSED CONTRACTOR DECLARATION
t 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
cv w Professionals Code, and my License is in full force and effect.
O 7) ch License # Lic. Class Exp. Date
LIJ 630403
7900
Z r, Date a " 7 Signature Of Contracto
CD 0 M
w U - OWNER -BUILDER DEC ARATION
UJ d I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) License Law for the following reason:
Z_ ( ) 1, 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,'6usiness & Professionals Code).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
C'') O I am exempt under Section , B&P.C. for this reason
ul
N Date Signature of Owner
ON
0)
d Q WORKER'S COMPENSATION DECLARATION
p Zcc I hereby affirm under penalty of perjury one of the following declarations:
U-) P O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W 4-- compensation, as provided for by Section 3700 of the Labor Code, for the
O � Q performance of the work for which this permit is issued.
M d I have and will maintain workers' compensation insurance, as required by
O C) Q Section 3700 of the Labor Code, for the performance of the work for which this
rn H permit is issued. My workers' compensation insurance carrier_ & policy no. are:
?. Z Carrier Policy No.
J
(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' compensaiiAon provisions of Section 3700 of�the°'Labor
Code, I shall forthwith comply with those provisions.
Date:fW` APPlicant�
4 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
fpr a permit 50lec1 t4 the pQnd.itigns and restrictions set forth on his F
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°putrpo s.
Signature (Owner/Date
Agent) �f.7`!"% �j
s r r
BUILDING PERMIT PERMTk °°NTRO
97{►1_07 4645
DATE �ingn VALUATION $4,977 LOT TRACT
ADDRESS 4'7-815 M% IRFAI�'E JOB SITE
APN
OWNER
CONTRACTOR / DESIGNER / ENGINEER
K111"W0i1
DA 1,11)NI GGNl'::.KAT.,rti'OIJ'!`IZ.A.0 CO.R
�31£i�t7 4'it1 4f:Cki;T N
30235 "K CDEL'YFERN40
LA.O1TKIA, (`'.A. 92253
CKJ714FN)RAL W V Cn. 922M
(619 70-(1260 CBL'P, 533
USE OF PERMIT
-PATIO ,
AtilJ id11W Mt ;XF. PA740 i ,WrikK. WD Bf1RW5 QUG
03 Al ED MST OFCOINSTR CITION
iy.CiktflI1T. '*?PRF Sfil'!irMA,RY
'C4. AN CH-9,CK FEW 101-000-439-318
SAF>N IMIY11TION''t-101 WIAM418-0m, S72.00
aP , M111•%5 r PIC
`i'I'OW $.50
s
_?TAA, CIONS TUX,11019 AND P11' t C'11ITK
6�
'wt)TAJ, PERIN'Eff FRINN. `CiOF,1iOW
$138.80
s
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings Y
Ducts
Slab Grade I
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 PPO ALS
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
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)