0311-191 (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
Ia029 U I3JMC:,'"'� ;.R73II
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Dates t51t.� Signature of Con rt actor i Ail
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.
�(�4t I have and will maintain workers' compensation insurance, as required by
Sktion 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 80TA!E C.OMMISATI Policy No. 232607-03
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.Califorriia; and acee that if I should become
3 subject to the workers' compensation provisions of Sectioni'3700 of the Labor
Code, I shall forthwith comply with those-provision{s.
�rDate: '1 '! �rtt Applicant k-, J A d ,
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
fora 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 ins I ection purposes.
,,✓ r '��
�� gnature (Owner/Agent) � .-= � t �n � -...,Date 7 � 1'
1 ,
BUILDING PERMIT PERMIT" . -
0311-191
DATE 02416/2MVALUATION D,fZ'9� 7.ORJ LOT TRACT
JOB SITE
ADDRESS 78..t 00 V A SEXY..I.��A
APN
CONTRACTOR DESIGNERENGINEER
RNMEM-1 LMT,0DyA
JP CORICrTRI U01I0N
TA C)tTiNTA. t A 92253
11+TD10 C71, 92201
(760)4.27.7701 CDL#
USE OF PERMIT
PATIO
550 SQ. Ter. P.dl'f10Jf.FZCK Piz,.. 1£Wi1b14ZZ.ii1 D .Pf f+,N.S
FORC H/P.ATIO 550.00 SF
PLAN CHECK F89 101-000-439-318 $64,35
CON5TKUC'fJtra 'FqI 101-000-418-000 $90.00
l LECTRIC'AL RU? 101 ^000-420.300 $2.d,St1
S"f ROT40 MOTION FEE - RZSID 101-000-241-000 00-241.000 $a73
p b% A
FE6 2 0 2004
CITY OF LA QUINTA
DEFT.
FINANCE
's"dJ -` OiAL "ONUI:RU'CIUC'13ld' AND PLOT CE K
$186.36
I.�R�I3 T��T;'.�e.FTJ:E?L7I✓'�
`�fi,tis:
DME NOW
V
RECEIPT
DATE
.BY
DA I SPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
Slab GradeReturnAir
_ _
3
Underground Ducts
Ducts
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
Framing
Insulation
_
0 ` _
F.A.U.
Compressor
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)