9910-135 (SFD) LICENSED CONTRACTOR DECLARATION PERMIT#
" C, I hereby affirm under penalty of perjury that I am licensed under provisions of BUILDING PERMIT "MIJ5
,. F= Chapter 9 (commencing with Section 7000)of Division 3 of the Business and J�r-i IA, DATE VALUATION LOT 2 TRACTW Professionals Code,and my License is in full force and effect. 1 1 t
-� ch License# Lic.Class Exp.Date
�,O JOB SITE
69OC4y 13 (W DDRESS "470 ASR APN 7 �
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Z 47ate Signature of Contractor -• - ?' OWNER CONTRACTOR/DESIGNER/ENGINEER
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OF C:) OWNER-BUILDER DECLARATION RJT H041,1EIS`-L I X RJT'!l:'�J€'S�,1E"�`I'S,IN91C.
-J P.G BOA 810 1 E.bf�tlb'1r.(ZS1�'i'Y MVE
H d I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) License Law for the following reason: LA(XIN'P.A CA SY2233 1H(.mt IX AL 85034
Z_ ( ) I, as owner of the property, or my employees with wages as their sole VRI Is 4W.
compensation,will do the work,and the structure is not intended or offered for
sale(Sec.7044, Business&Professionals Code). USE OF PERMIT 11111111102
( ) I, as owner of'fhe property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals SiN�ihE l:A1v1iLY UW>Hi,1,lNi IE
Code). S D-L0 f PLAN 2R.13ERUIT EK%.1i zvGT i�rfi BI.O W AU i:�li
I am exempt under Section B&P.C.for this reason
Ln L JOL
N Date Signature of Owner
ON
rn
d Q WORKER'S COMPENSATION DECLARATION - — - - — ---- —
p Z I hereby affirm under penalty of perjury one of the following declarations:
O ( ) 1 have and will maintain a certificate of consent to self-insure for workers' MS` OM(.10NST'RI;MON Z577.00 SF
X W compensation, as provided for by Section 3700 of the Labor Code, for the 110RCUIPAf10 2112.(10 SF
O J Q performance of the work for which this permit is issued. �bA1tA(i�ihGAltlK.t4t7 SF
C0 Q U (N4 1 have and will maintain workers'compensation insurance,as required by
O (-) Q Section 3700 of the Labor Code, for the performance of the work for which this I
rn F— permit is issued. My workers' compensation insurance carrier & policy no. are:
,It Z Carrier Policy No.
000 0 T4 A.W, 01Z T WDE]">X!•i]` 0 un1 TFE.D CMOf CONSTRUCTION 214=40
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(This section need not be completed if the permit valuation is for$100.00 or less). PE 1�U SOMM.ARY
( ) I certify that in the performance of the work for which this permit is issued, (_•'0N3TRU4_11`1f-)N FEE 101-000-4184M 51.04100
I shall not employ any person in any manner so as to become subject to the P1 AN Vt W('K FR1 I0J4XX)_4V_318 g"7 F?
workers' compensation laws of California, and agree that if I should become 11tV 1IANUVAL rM, 101.17eW421-OW $111.50
3 suNedt to the workers'compensation provisions of Section 3700 of the Labor
C, e, I shall forthwith comply with those provision F�(Cst CRt�.f1l FE& 101-000-420-OW $159.34ate: Applicant k---- �" PLUMBIW-1 FEE 101-000419-M 1199.30
Warning: Failure to secure Workers' Compensation coverage is unlawful and STRCINO W)�N�F-RFIRM to!4X)4-741-0w t'Tl 49
shall subject an employer to criminal penalties and civil fines up to$100,000, C�L
in ADINC ITsEi .4Q
1010�•423-000 5 .00
luaddition to the cost of compensation,damages as provided for in Section 3706 DhVFs1.k*IEK 1t+4+PA(.1"'FIX
of the Labor Code,interest and attorney's fees. ART IN 3+tfiitA PLAt_.9' -[!6811;[!6811;701-000-2545-W $207.1.4
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, indemnity S[TB-TnTAI..,(70NMI.l�'"1' ON AND PLAN CHFVK $4.W. Rd
& hold harmless the City of La Quinta, its officers, agents and employees. ,ESS P".-PAID VFES soW
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. FOAL. PERMIT F'ERS DUL NNW
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 F
the bove-mentioned property for inspects pu poses.
RECEIPT DATE eY DAT F ALED INSPECTOR
tSignature (Owner/Agent) Date '
INSPECTION RECORD
OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR
BUILDING APPROVALS . MECHANICAL.APPROVALS
Set Backs Underground Ducts
Forms&Footings Ducts
Slab Grade 2 Return Air
Steel Combustion Air
Roof Deck e. !i(J _ �i Exhaust Fans
O.K.to Wrap F.A.U.
Framing —7 W Compressor
Insulation =�� 4 Vents
Fireplace P.L. Grills
Fireplace T.O. Fans&Controls
Party Wall Insulation Condensate Lines
Party Wall Firewall
Exterior Lath 3
Drywall-Int.Lath cu
Final
Final f1—C4 POOLS - SPAS
BLOCKWALL APPROVALS steel
Set Backs Electric Bond
Footings Main Drain
..Bond Beam I Approval to Cover
Equipment Location
Underground Electric
Underground Plbg.Test
Final I I Gas Piping
PLUMBING APPROVALS Gas Test
Electric Final
Waste Lines Heater Final
Water Piping Plumbing Final
Plumbing Top Out Equipment Enclosure
Shower Pans OX 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) - e::d-