9712-072 (RER)LICENSED CONTRACTOR DECLARATION
i9 (fir Thereby affirm under penalty of perjury that I am licensed under provisions of
I- y ChapterA9 (commencing with Section 7000) of Division 3 of the Business and
cel `i11 Professionals Code, and my License is in full force and effect.
�r2 ,M = icense # Lic. Class` ( Exp. Date
NIL
LO 694957 8
Z ti VDate Signature of Contractor
(�0 0 C
J U C:) OWNER -BUILDER DECLARATION
HLU I hereby affirm under penalty of perjury that I am exempt from the Contractor's
fn License Law for the following reason:
Z_ ( ) 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
LO
�! Date Sigriature 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.
(Xy 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 Policy No. '
nxrj.�'�.
(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' compensation provisions of Section ,3700 of the Labor
Code, I,shall orthy�Ith comply with, those)plovlsions. -
Oate: �� �( P- i Applicant
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
for a permit subject to the conditions and restrictions set forth on his
1. Each person upon whose behalf this application is made & each person at
w 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 int:"
ection purposes.
j'�i' f!
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VSignature (Owner/Agent) ' Date !2
PERMIT# CONTROL# ,
BUILDING PERMIT
DATE VALUATION LOT TRACT'
JOB SITE Ir ADDRESS .h + j it, -
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APN , 761-4d'i1.)39
- - `
OWNER R CONTRACTOR /DESIGNER/ ENGINEER '
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&i `y!.13�i11 L,F� Sfvt; i':1' t3i�i3?:�i",�f1�i�S C't:�A:S'Ciri.I'"t3Ad
12- tTRNING I'RECI RD 79-920 i:d� yUk DKIV13.
' i` Ii?itt/k):it'f.' �3.F_rACH CA x'26.60 1,A, QUlTdTA CA, 322.53
t f17604775-:933 C 31, :_3212
USE OF PERMIT
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ADD Siia'1` FPS BAR IN MKISirixdG 110ME A41 LJ,
DEC 1819.9
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t z C•Itl.:� z 101••0W ,.f `{1.'JOti $it3.ttCt
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RECEIPT
DATE
BY ' "'-
DATE FINALED
INSPECTOR
r INSPECTION RECORD
OPERATION
DATE
INSPECTOR OPERATION
DATE
INSPECTOR
BUILDING APPROVALS MECHANICAL APPROVALS
Set Backs Underground Ducts
Forms & Footings i Ducts
Slab Grade ,1WReturn Air
Steel Combustion Air
Roof Deck Exhaust Fans
O.K. to Wrap F.A.U.
Framing - - Cr Compressor
Insulation 3�C� — �y 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 Z
POOLS - SPAS
BLOCKWALVAFkOVALS
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)
ELE :TRICAL 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
r.
Final
Utility Notice (Perm)
REGISTERED INSPECTOR'S WEEKLY REPORT
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JON T yF &wn� "e
k
3580 Con"'&;�284"te, A
Yucca Valley, ;
(760) 365-504 r l
TYPE OF
INSPECTION
PERFORMED
❑ REINFORCED CONCRETE ❑ STRUCT. STEEL ASSEMBLY
❑ POST TENSIONED CONCRETE ❑ ASPHALT
❑ REINFORCED MASONRY ❑ FIRE PROOFING
❑
❑ OTHER
:1
JOB LOC
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REPORT SEQUENCE N0.
TYPE OF RUCTURE
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PE T1�0`
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DAfEj _ V-GY DAY OF WEEK
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MATERIAL DESCRIPTION
ARCHITECT
P
INS EC R, MRS. CHARGED
(\JN
ENGINEER o
ASSISTANTS HRS. CHARGED
INSPECTIONGENERAL
DATE
\
SUB
CONTRACTOR OJ CONTRACTOR
19.
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COPY SENT TO CLIENT ❑
CONTINUE ON NEXT PAGE ❑
PAGE OF
CERTIFICATION OF COMPLIANCE
I HEREBY CERTIFY THAT I HAVE INSPECTED TO THE BEST OF MY
KNOWLEDGE ALL OF THE ABOVE REPORTED WORK UNLESS OTHERWISE
NOTED. I HAVE FOUND THIS WORK TO COMPLY WITH THE APPROVED
PLANS. SPECIFICATIONS. AND APPLICABLE SECTIONS OF THE
GOVERNING -BUILDING LAWS. '
It rr- �I$?�U � Q� REGISTERED INSPECTOR69q?,k
DATE.OF REPORT`/—'eR''��GfSTER NUMBER