0002-0407 (RPL) p LICENSED CONTRACTOR DECLARATION BUILDING PERMIT PERMIT#
J _01=+"I hereby affirm under penalty of perjury that I am licensed under provisions of
- CA Chapter 9 (commencing with Section 7000)of Division 3 of the Business and DATE �^ VALUATION g!1ltNfllt9!! LOT [ TRACT 2K;97
C14 W Professionals Code,and m License is in full force and effect. tjl�&Id
O M ch License# y Lic.Class _ E. Date
W U.) (;90&45 13-- 061'30!2 N JOB SITE ADDRESS 79-•�*Rl1J t'q_-ULkR APN 769-460.008
oZ r- Date�' Signature o6 f Contractor f'F /- OWNER CONTRACTOR/DESIGNER/ENGINEER
� O - t,F'i'Iif'tii1CC' rr;+ �40.,Xrvj tAof•
H OWNER-BUILDER DECLARATION '+' "' • • + *"^ •-,.�.
U co il.0 lbOX 6 i 0 1425 E.t NIVEWS.rT Y DRIVE
FW- WW I hereby affirm under penalty of perjury that I am exempt from the Contractor's -A til 11N t'A CA y225 ti krf fUk NlX A1., 85039
License Law for the following reason: ft41fi56 (.131.4 4090
Z_ 7}7�7_f( ) 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 • 'I,(,J(Jl, tkNl xuR SPA
contractors to construct the project (Sec. 7044, Business & Professionals
Code). - 1't•1�.i1..x:ii•t'�4JNR.1^r1CtlEct�usrtlNlttcli:�cS St><Ai.t.j5r:ltti k'>ae�i.'�e1:1 !'.iL ;
Ce)LO () I am exempt under Section B&P.C.for this reason 1+LAS'f'!:1{tl4,ylr}:CTI(jN
N Date Signature of Owner
ON
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CL Q WORKER'S COMPENSATION DECLARATION
C) 2 Z I hereby affirm under penalty of perjury one of the following declarations:
Lo H p O 1 have and will maintain a certificate of consent to self-insure for workers' POOL �tMF3•'nii';i7�1. 10,t1C10.?0 T.1i
X W �= compensation, as provided for by Section 3700 of the Labor Code, for the
Oro J Q pe r. ance of the work for which this permit is issued.
Q U have and will maintain workers'compensation insurance,as required by
O U Q /Section 3700 of the Labor Code, for the performance of the work for which this
0 H permit is issued. My workers' compensation insurance carrier & policy no. are:
Z Carrier �,,� , .l x�q i�r ,,m Policy No. r+tr�+uTlr►xr�+ �rv�r see r��eca n,a
cb uv+.+.��t►f i'tiL`."1 Of.' 1. 4T 4., +11,!,`N 1,Vt/ 4.�:a'A.�f ,x.11.a.:,li 1,V+ A4 Vl' t.\�l Y,.�k.Li,%A &,-ft M sFF�W li It 4/
Q (This section need not be completed if the permit valuation is for$100.00 or less). pf"IRM3! FEE,aWWWAR
( ) I certify that in the performance of the work for which this permit is issued,
PLAN CUL-XIX FH"El 101-000-439-1I8 576.05
1 shall not employ any person in any manner so as to become subject to the r`f>?Y!°;I`►2irt't'(t3rdFFf jfjl-tKlfl-, fft 11fKl $Ij7.410
workers' compensation laws of California",an`d•agree that if I should become Mj'X.31;yidl`Cr".t 071s--1'OOL 11011-00-42 1-000
3 subject to the workers'compens n provisions of Section 3700 of the Labor 1;jt;C RICAL t,-I~:i;--t 001 101-000-420-000 545.00 `�` :
Code,I shall forthwith comply with those prdvl ons. a
,Date: f-`? ' Applicanff2 `5�`'� PLOM.BiNO FEL POOL 101-000-419.000 $2710 � � .
Warning: Failure to secure Workers' Compensation coverage is unlawful and 4.
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 37061
of the Labor Code,interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety `! (r}
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 S;1 I R J'QT AI.f-Y0'1VK'MJ lC r1lQN KlL)P) AIN C',�II C K $?g,1 ns
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. i,x�'.r+ I'1;1;•4'ril(`•F f;3 ti �r•t).0t!
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 TOVA-1,PERI IC117 F t+N il)UC'Ni'>WV
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 I IIIIIII VIII III VIII IIII
• correct. I agree to comply with allCity-and'State laws relating to the building 75
construction, and hereti`y authore"representatives of this City to enter upon IE
the above-mentioned prope ,for inspection°purposes.
/ ( C RECEIPT DATE BY ^ '�'' DAT F ALED INSPECTOR
Signature (Owner/Agent ``�` Date � �
v
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 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)
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)