0011-280 (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 # ' Lic. Class Exp. Date
Ci13aJ Bob 0 11 f
Dat `Signature of Contractor A93
OWNER -BUILDER DECLARATION.
I hereby affirm under penalty of perjury that I am exempt from the.Contractor's
License Law for the following reason:
( ) L, 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&PC for this reason
Date Y/- Z �� Signature of Owner
WORKER'S COMPENSATION DECLARATION'-"
I hereby affirm under -penalty of perjury.one..of the following declarations:
(;) I have and will maintaina certificate,•of consent to self-irisuie>for workers'
compensation, as'provided for. by Section 3700.6f.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(ry Policy No.
LA
(This section need not be completed if the. permit valuation is'for.$100.00 or less).
O (.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 1 should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Codeel shall forthwith comply with th.g§e •proveshon R S
. 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'Section3706
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 ton tiis
application. (,
1. Each person upon whose behalf this. application is made & each person ate.,
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 Quinti, 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'can6.ellation.
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. .+ ' '
sig -nature (Owner/Agent)Date
•.... ..PERMIT# -
BUILDING PERMIT
DATE VALUATION LOT, 041)11;-260 TRACT
JOB SITE
APN
ADDRESS bra sq rh ��r test pqs
76-925
'
OWNER
CONTRACTOR /DESIGNER /ENGINEER
M& hW. JtOLA
77bR COYSIRtJ0017 CIO,
3W.91275 V'Z111OR IT(IT
18.155 CALLS VORTILT 'A.
CA., _ 92233
LP,, QYi`�larm CA. 92253
Ol' 1't'�8tY`Y 1 C��i f�.. - 6238
USE OF PERMIT
PA.C'!C)
WOkK Ei,90 UN WITE IOUT RLM PLY MIT. 3 A.LUNAWOOD =V9104 Pte:
ICBO *2621A .13'6" X 12'6ti l TTIC:C', 3->' X 5' SOI : r; E0° Y 9 It ..e OL ID
POROUPATIO OF .. ,
r. .
' qp .q'+�pt/�,�r�[ �+ ,{•q v.� /••� �+, �yq�+ •g•��•p�.yp�p
EXE&fJlPiATED F+� .O U. C+1.r�i:FB 0.1'i.. X,RV•7K�
s�9:►w�1,�v.�dW
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• PX1Rd31 D1 .0 JP R Cy V A9.RlV.P.1}AiK A9 .
PLAT4 CI-IIsC"K M tC)^QOi)-h39• l 64,39
CONSTRUCTION RIE 1tD1-0,,00-4I84001C
MOND MOTION PER - RMID • 101-iOOO-241.000 S172
Pt�i1�F�,57'1;AA'�1Ci�t :t�r;iu . • ... • . .. � ��-ro>�n-��:�-rte ���.oa�
il-`rC9TAtU, C()ARL, C-1T•61•i . 61.gyjucripm
$263. W
3. X E M PRE -PAW F,
sIi o
NOV"2'9'2000
RECEIPTDATE
BY��/ j'
ATNF D
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
I 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 r
BLOCKWALL APPROVALS
Final
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. 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)