9912-007 (SFD) J[3 LICENSED CONTRACTOR DECLARATION BUILDING PERMIT PERMIT# .
k, U), I hereby affirm under penalty of perjury that I am licensed under provisions of "12.4107
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business andDATE VALUATION uS2,.;,T it. 3 LOT TRACT MITI
CO Professionals Code,and my License.is in full force and effect.
O :) M License# Lic.Class Exp.Date y�'a
r- O LIJ LO 690645 B � a�{?J�{)r!2{3f A1013 SITEDDRESS TP-460 M'.{�AIMAt APN '7Fo'�- 66-M
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OWNER CONTRACTOR/DESIGNER/ENGINEER
oZ r- 0 to Signature of Contractor
CD O 1e4` "HON-41"Is,611.i, RaybIN
C.
r` H o OWNER-BUILDER DECLARATION
J U .�. �3 �5�4 142$F.UL,,{1g/fN@Za�,4i�.A� !VE
W W I hereby affirm under penalty of perjury that I am exempt from the.Contractor's
H n 'l,A("�UIT�I'Z A. CA 92213 PHOENIX NIX ,t Z 81,0314
co License Law for the, reason: { £.y7-I`;� �, ;�` ;���
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). USE OF PERMIT
( ) I, as owner of the.property am exclusively contracting with licensed SYNGLF PI ,DWELLIpt-s
contractors to construct the project (Sec. 7044, Business & Professionals
Code). qD-k.;0T 3,PLAN.3A..;K)RLOCK WALL 0R PWL.7Y%.C?L`D€,r<:1'£t'}N Aq
Cl) () I am exempt under Section B&P.C.for this reason t1EV(.11.WFAX A1u I; P£; R£� ) t•u;p d:rP�t fAt\t�:f�CtF:�;%a3lyt131�1,.t� i= LA %
N Date Signature of Owner r
Q WORKER'S COMPENSATION DECLARATION - ~
C:) 2 Z I her affirm under penalty of perjury. one of.the following declarations:
LO - O( ) 1 have and will maintain a certificate of.consent to Self insure for workers' CUSTOM b:.�e�F"I�i17� tabid 2,83,1002,83,100P
X W �: compensation, as provided for by Section 3700.of the Labor Code, for.the 11-JO,61.1INVI'i10 13u3ooSr
O � Q performance of the work for which this permit is issued. t3ARA«FJCA t!'C.X1' S'78. ti 1131'
m Q U ( I have and will maintain workers'compensation insurance,as required by
p.0 Q Section 3700 of the Labor Code, for the performance of the work for which this
• li 0 Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier d .� r Policy No. t y Ly W l7l�9 qIt•t; s
CO INS,�•.j, 1f 112�t'I( AAI%I:t.,f )41`�k"d1
d (This section need not be completed if the permit valuation is for.$100.00.or less). ' 3?g` ;.'bJf` i� 1ir$�'
J ( ) I certify that in the performance of.the work for which.this permit is issued, e�f).NS CRO.lf IRON FQ's $1,108.50
I shall not employ any person in any manner so as to become subject to the PILA1,4('fJ sC.'•.1111£'FY; 101-W, -,439-318 $2.26,50
g a
workers"compensation laws of California, and agree that if I should become db1EG°PILA:JiO;+E.:fr 1 ?f)'j f)dp(}., :ZI_�} 8105.08
sub'ect to the workers'compensation rovisions of Section 3700 of the Labor
�� P P ]„�'�:t'l41CAL I
Code, I shall for w1 h comply with those pfoGision�s x t
(Sate: J.�l-�I� Applicant— / r�' �,. .Q,jtl9k�.£ 1��t F#e 1.01-f,3W-419-OW $.t80.V t.
8T�t(3?!�S<11 NA01ra0N'F,ME:-tZ�? iD Etl1, 4ri1L�-motif fl±�(P "���:3? f'"Y ; ►!',
Warning: Failure to secure Workers'Compensation coverage is unlawful and GilikI 'UNI:9 FITZ
shall subject an employer to criminal penalties and civil fines up to$100,000,in ;w ;
addition to the cost of compensation,damages as provided for in Section 3706 I3k?N3?€(iTai d �1'At:%t1 3y St, �sl'Ot9 M f i s!-.
of the Labor Code,interest and attorney's fees. eil T'IN I- Bt:.tt;;,P),:�:�t3-E SIE.701-OW.':q.`f>tzW
IMPORTANT Application is hereby made to'the Director of Building and Safety
fora 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 applicator agrees to, &shall, indemnify �`yt��+3'TCW f�CONS1�T-KNIO`,AN'D PLAN f1k`3C K_ $4jW13 46
& hold harmless the City of La Quinta, its officers, agents and employees. LESS Plu..g°i�ID 4�ii'��+ ��:W
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. �)"fair '.°�1i� 9' +'1?: ;�4�^ �38 j�EA +! `S�' ��3•dt5
I certify that I have read this application and state that•the above information is IIIIIIIII I I IIIIII�II
• correc�l agree to comply with all City, and State laws relating to the building 79
construction, and hereby authorize representatives of this City to enter upon N . , IE
tabove-mentioned property for inspection purposes. 0 _
RECEIPT DATE BY' DATE FINALED
7 INSPECTOR
(Signature (Owner/Agent) Date
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 Wall Insulation Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall-Int.Lath
Final
Final POOLS - SPAS
BLOCKWALL APPROVALS Steel
Set Hacks Electric Bond
Footings Main Drain
Bond Beam Approval to Cover
Equipment Location
Underground Electric
Underground Plbg.Test
Final I 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
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp.Use of Power
Final
Utility Notice(Perm)