9910-136 (SFD) LICENSED CONTRACTOR AR DECLARATION . � PERMIT♦
r� U) I hereby affirm under penaltyof erur that I am licensed under provisions ofBUILDING PERMIT
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and DATE VALUATION . LOT TRACT
C14 N ' Professionals Code,and my License_is in full force and effect. 2r<Dfvti � � 0 �• ��
O LU
n M License# Lic.Class Exp.Date+,
W r VC � t?frl iii {tt ADDR SS i1� 9 h�ila�lCsflyr. APN �ifj-•'�C8 41f
Z spate /�•i J ./moi Signature of Contractor •� OWNER CONTRACTOR/DESIGNER/ENGINEER
CD 0— r s
J U OWNER-BUILDER DECLARATION . T=jl; )a rj;�'. jv'1`�'.Tfi1VEIUh�"Yl;?'�1!�,T1`:€.:.
H LU I hereby affirm under penalty of perjury that I am exempt from the Contractor's P?o Box 8.l'{� �'���E.�r�3VVE CrY:DRIVE
License Law for the following reason: !,A E.,,?(:.t;}.V),'A CA 92253 PHOENIX NIX JAZ 85034
Z_ (. ) I, as owner of the property, or my employees with wages as their sole (W)2.574656 Ci`) LJ, 4M
compensation,will do the work,and the structure is not intended or offered for
sale(Sec.7044,Business&Professionals Code). USE OF PERMIT
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals 8}i+)`CiLIE FANKL 1_)W...Lfl%3
Code). a
cO () I am-exempt under Section ,,, B&P.C.for'this reason Ste'•.€.OTf 1 PI:�A?;P I-,'Ph2htiF.!'tXC3%5 T?aC>',t'13dC7.TIpt� ,11. � 't�lflT.L i"ati'
NP(,Id)t. 1,50,,i J$�j�.OCE ION ON f•� AN(:.4F,(;.K.FEE FOR(vf.Ct1.`2'.I.mu?,l s�S'i.fdti:Pr4az
Date Signature•of Owner
C)'SAk 61-I€.Ali TYPE. ,
2.< WORKER'S,COMPENSATION DECLARATIONCL
'
LO Q Z I hereby affirm under penalty.of perjury one of the following declarations:
r O ( ) 1 have and will maintain a certificate of consent to self-insure for workers' GMT Ohl 00NS"i'13tila""ir 10N Z 70.001 r,
X w compensation, as provided.for by Section.3700 of the Labor Code, for the s .ECf��+;ATyO, l 2,00:Y
O J Q performance of.the work for which this permit is issued. C:;A€tt#Crk1+ A4Z4�t�4�#' fs: r.fi0 Sfr
m Q L) ( ) I have and will maintain workers'compensation insurance,as required by
p U Q Section 3700 of the Labor Code, for the performance of the work for which this
rn H permit is issued. My workers'compensation insurance carrier &'policy no.'are:
,It Z Carrier Policy No.
dN'13.("o tv1b. L 4y'C� 'i: yS 7E.1^t TSf�O ""S1 'I `l' !:P3 � '� $':01%f�i;;),3 '�:"�0i�f 206,17'2.20
J (This,section need not be completed if the permit valuation is for$100.00 or less). �'�+°Rf5�U FEW,SU MARS
( ) I certify that in the performance of the work for which this permit is issued, CONS`€RUC."S"IOIN E'R E
I shall not employ any person in any manner so as to become subject to the PI ANr7f:3t3E-;yZ,{: fP�� j {j-ARt}w?jt3 5?IiR,f
workers,- compensation laws of California, and agree that if I should become
10E01IINICAE fiCfM SzaI-UtE.4� l:t-� � 1ff�.ft0
subjec•'f to the workers'compensation provisions of.Section 3700 of the Labor ;
C/de, I shall forthwith comply with those provisions.
,pa Applicant
..i�-�.�; gPplicant % c` !'I.I,INIHINO t NE lfbl-�f} -4 !-(B Ti Igo.443
' 4T'f7;Cf }u}()°f it��1: 0 f~_ F.�4'P� t)6,-(W-7414)!i3bl
' 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 OR11VINC FIX tom?- $e fr.Gt�r
addition to the cost of compensation,damages as provided for in Section 3706 DEV l:�t.01'%C WTIAi::C 01P,
of the Labor Code,interest and attorney's fees. ART 1K PUBLIC 11L A(M3-1,kt£SkI:70 140)-255-000
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 15M )Tr.`L f,ONIS—' R<9cMIC)N ANI)f'i,.AN CHj. X
& hold harmless the City of La Quinta, its officers, agents and employees. [HK ��j ?�,j,;�'���t� $0.00
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 applicationand state that the above information ir` IIIIIIIIIIIIIIIIIIIIIIIII 8()
• correct. I a ree.to comply with all City, and State laws relatingto the building
construction, and hereby authorize representatives of this City to enter upon /� IE
thab ve-mentioned property for inspection pur oses. N C-+
j RECEIPT DATE BY DAT F L INSPECTOR
IS�Dnature (Owner/Agent) --y Datey
INSPECTION RECORD
OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR
BUILDING APPROVALS MECHANICAL APPROVALS
Set Backs a q _ _ Underground Ducts
Forms&Footings Q _ Ducts
Slab Grade /��_J,( _ `/ Return Air
Steel L Combustion Air
Roof Deck Exhaust Fans
O.K.to Wrap F.A.U.
Framing Compressor
Insulation 7
Vents
Fireplace P.L. Grills
Fireplace T.O. Fans&Controls
Party Wall Insulation Condensate Lines
Party Wall Firewall
Exterior Lath C--Cf
Drywall-Int. Lath �Z
Final
Final -
Gu - 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 i
Water Piping Plumbing Final
Plumbing Top Out Equipment Enclosure
Shower Pans O.K for Finish Plaster
Se Lateral Pool Cover
,ewe Connection _Z _ 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) —d*C-