0211-207 (MISC). LICENSED
'CONTRACTOR DECLARATION
| hereby affirm under penalty cxperjury that | am licensed under provisions of
Chapter 9 (commencing with Section 7000)mDivision oofthe Business and
Professionals Code, and myLicense ioinfull force and om,ct�
. uuvnuv# ` uo.o|ax� '� Exp. Date
C53 .'fiaQ C-8 IVIM2(
Date Signature. of Contractor
�VVm�M��W|�Q�RQ��LAR�DO0 he.r�b`y affirm under penalty of'oerjury that I am exempt from the Contractor'sLicense La%v for the following reason:�'(,as� owner of the property, or my employees with wages as their sole,compensation, will do thework, and the structure is not intended or.offered for.contractors to construct the project (Sec. 7044, Bu.siness & ProfessionalsI am exempt under Section B&P.`C.ofor this reason.01 Date —Signature of OWneWORKER'S COMPENSATION DECLARATIONI'hereby affirm under penalty of perjury, on6 of the following declaiati6ris:-
and will maintain a, ertificate,of consent to self sure foe w rk6rs',performance of the work for.which this permit is issued.I h�ve and will rn�intain workers' compensation insurance, as required bySection'37bo of thelabor�Cocle, for the performance of.the work for which thispermit, I is issued. Myworkers'.,cornp . p . n . sation insurance -.carrier &,poky no. are:.Carrier Policy No.,,,��is section need:not be completed if,th6 permit valuati6n.is for $166,00 or lessy.I certify that in the performance -the work for Which this permit is issued,.1.tall not employ any person -in any manner'so as to'bec'o'rne subject to,ihbsubject to the workers' compensation provisions of Section 3700)of the' Labor ADate: /0-2. ApplicantWarning: Failure to secure. Workers' Compensation coverage is awful and.,,shall subje8t an employer to criminal penalties and civil fines up to $106,000, in�qdition to the cost of compensation, damages as provided for in- Section 3706of the Labor Code, interest and attorney s fees.IMPORTANT Application -is hereby made to the'Director of Building0nd Sa*iet'yfoe a -,permit Subject to the c . onditi6ns and restrictions se . t forth on his1. Each person upon wiIose behalf this application is made & each person atwhose- request and for whose benefit work is'p(�rformed under or pursuarlitJon * a Oerriiit issued . as a result of this applicaton agrees to, & shall, inderril4fly&'hold harmless. the City of. La Quinta, its off icers, agents and employe4s.Any permit'issued as a result of this application becomes null and void ifWork'is not commenced within 180 days'frorn date. of issua�ce of suchpermit,,or cessation of work for 180 days will subject permit to cancellation..!.certify that I have rea,cl,this application and state that the above information, iscorrect. I agree to comply with all City, and.State laws relating to the buildingconstruction, and, hereby authorize representatives of this City to enter upo,nthe abovd-mention6d�propertyf& inspection purposes-,.)
-BUILDING PERMIT
DATE- VALUATION LOT TRACT
JOB SITE
ADDRESS
APN
OWNER
CONTRACTOR/ DESIGNER/ ENEINEER
47 -910 V1h ZUX-f0i
86-100 AfflOW.I.E. 54
LA QUWTA CAT 92253
COA1,7514ELLAk CA, 92236
00355
USE OF PERMIT
OR IRRALBIRLDIR0
S FT., WALL U00 LF
CONSTRUCTIQ9 FEE. 103400,418-000
Torm ry–MiT ms DUE HOW
RECEIPT.
DAT�//
DATE FINALED
INSPECTOR
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 Wali 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 L,Z- . d L
Approval to Cover
Equipment Location
Underground Electric
Final g pZ
Underground Plbg. Test
Gas Piping
PLUMBING APP OVALS
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
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final, .
Utility Notice (Perm)
COMMENTS:
�•r