0206-135 (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 , _1N1Jxp. Date
260-484, B .-'u
12131 * 0121
Date �' 1.' �- Signature of Contractor''`
S
OWNER -BUILDER DECLillITION
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
Sec ion 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 STATE FUND Policy No. 229.020OD3495
(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 Califorxria,,and agree that if I shrould become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply wit I�Ithose prov bns�_
Date: r' �r� 1- Applicant i.
Warning: Failure to secure Workd�s.Gompensation coverage is unlawful and
shall subject an employer to crimina enalties 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�ws relating to the. building
construction, and hereby authordze representatives of tris City to enter upon
the above-mentioned p- pert ��,for spectjbn pt res. ,
Signature (Owner/Agent, k Date
BUILDING PERMIT PERMIT#
•. •�•
lVi.RFCl'-9..78?
'TRACT
DATE flef", VALUATION $7,V430 30 LOT ,'
JOB SITE
ADDRESS 47-90.5 it�Al3 i� �
APN
OWNER
CONTRACTOR/DESIGNER/EN (NEER
F-T,N t,r S.e3,D4
PIs I TIER f"t)NM,$ICTION
VIATRUWnS
74691 3WMWILLROAD
.47-905
LA, QPW A CA 92253
';'"€IGUI-JAND PAXiMS CA. 92776
7t)1),275e6017, CEUi 310*6
USE OF PERMIT
PAMO
373 IF°.ALi MA41i't1OD F'.ATiO COT/W.
POR HMATIO V
WNUTidATED �d3�" Or, Ct3N4:I:RU«d(' N
PkIZ'M ;C JITE SUMMARY
MAN f:NECK. FEM 10)-000-439.318 $64.33
CONS°t'i UCrION FLIT 101-00"18-000 $99.60
°a3TROW.3 X40TIO+N FEE RFAII? 111 41 -000 S36
s
p�7yy�� +7.�cy 1� �+�
V1V.G.�^,/. - si GOMRUCT10.1 ADD Y'-i.A1q MM
64.11
LESS PRE"PlAWTV.S.1
$0100
D1' L PEI RNUTTAIMSINJE ff OW
$1614111"
JUN 110012
CITYOFLAQU11ft,
FINANCEDEPT f
RECEIPT DATE`��'4 f^+k
DATE INALE�
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 8 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:
POOLS - SPAS
BLOCKWALL
APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground PI . 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
Lew Voltage Wiring
Fixtures
M in Service
Sn Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
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Li -7 a o oa oo,(r,e.�, K
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CITY OF LA QUINTA
BUILDING & SAFETY DEPT.
APPROVED
FOR CONSTRUCTION
�l �--_
A RE -INSPECTION FEE OF $30 .
WILL BE CHARGED IF THE APPROVED
PLANS AND JOB CARD ARE NOT ON;
THE SITE FOR A SCHEDULM
INSPECTION.
.NO EXCEPTIONS!.