0002-408 (RPL) f wt'` i ,.4 LICENSED CONTRACTOR DECLARATION BUILDING PERMIT PERMIT#
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I hereby affirm under penalty of perjury that I am licensed under provisions of f S�If({x.�Uti
F- Chapter 9 (commencing with Section 7000) of Division 3 of the Business and DATE 111 VALUATION S10.411110.90 LOT 6 TRACT 711797
WProfessionals Code,and my License is in full force and effect. 4/
License# Lic.Class Exp:Date N JOB SITE APN
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Z Date �"� Signature of Contractor�)� � "���� OWNER CONTRACTOR/DESIGNER/ENGINEER
coo O f e r iar�n ti;e 1 i r� n r r�r)t►r�r•n xr;n•pr� i�tr
r,- H o OWNER-BUILDER DECLARATION +• ........... ....-. �. x „ ..,..1...,,.. ..,, ,..
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W W fhereby affirm under penalty of perjury that I am exempt from the Contractor's ,i'.G BOX 8 i 0 W25 E. (JtNIVE .SUy DIVI E
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CLI'A QUIN I'A CA 97253 PHOENIX AZ 8.50W
License Law for the following reason:
Z ( ) I, as owner of the property, or my employees with wages as their sole (t+U717S7-+656 (;f�Y,#( 9��Q
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 K)C)j,ikNl.?OR SPA.
contractors to construct the project (Sec. 7044, Business & Professionals
Code). K,40L&,SIPA ONL V-tiE.AW%i&1-3A'Ucir:RS irsiir%il psi:itrri�i����u ski PRE
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O I am exempt under Section , B&P.C.for this reason ►'t,r��r't"i tt[NS1'T'f-t'tl+N
N Date Signature of Owner
ON
CA
d Q WORKER'S COMPENSATION DECLARATION
C:) 2 z I hereby affirm under penalty of perjury one of the following declarations:
Lo r H O O 1 have and will maintain a certificate of consent to self-insure for workers' t1NUlvI`SPA 10 U Wit'
X W Y= compensattiio� as provided for by Section 3700 of the Labor Code, for the
O J _J perform cE of the work for which this permit-is issued.
m Q U ( 1 ,�e and will maintain workers'compensation insurance,as required by
Q U Q �ecti n 3700 of the Labor Code, for the performance of the work for which this
11 rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
It Z Carrier •„, sr.,. r ».i< Policy No. ,.n •�� ,.r �r1/ t s�rr►*a r�1ss/Yrta•�r•rlbn r��ntc�r►�rrw ir�rT • -j•,sn Imon nre
07 �1Is.CoR,.E,ri a. 4,5' t. Ysj/l)5,1 1L��VV a's1►tnl�Xtix i�Y,i l+4�h�t \,1¢ -\..111�J X.ii Y.1�•Y \!i1 _
O (This section need not be completed if the permit valuation is for$100.00 or less). il� . IV! ' ��tiif,`Y� $A.R��!
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J �PLA.N l:ttf CK FFH IU1-UW)-� -�1�5 S76.01y x
( ) 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 rat>djTi' iir:nP'1N1<'r p 101-OW-419-000 $197 of) �^� r �l •j
workers' compensation laws of California, and)agree that if hshould becomeXSi Cl,'�':Nf;11;,f"1 f's •-n:)iJ.L 1011-000-42] QQQ 4�•i.00 F t'`
3 subject to the workers'compensation l
provisions of Section •700 of the Labor
�;.. . , -- `1'siit;At.trf #:--POOLu101-000-420-000S.•3�,du r,r
Code, I shall forthwith comply with t ose provisions \
Date: % �`APPlicant '�;� �' t'1 wlMtllNtt i'ESI --1'C!()l WI-OW-419--ft) �27.rtf ;-,
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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
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 tYYT 1,C_tl�l.WR 1 J(4t Tf)y•�1N1 1 PLAN(",11TH K. �74�1(Is
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. LESS P1:;3-PI"¢ID "EM"i �if;,fl0
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 4,0 A€,&'K# MJ*f VMS 0110 NOW $149.415
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 IIIIIIIIIIIIIIIIIIIIIIIII 71
• 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 r IE
the above-mentioned propert,,fesinspection purposes. � �`
! /,�' .�•/`� � RECEIPT DATE BY 1,}� i/"1�jt DASE,FaALEq � � INSPECTOR
Signature.(Owner/Age'`nt))., t '"""--"—tJWe�?��� YtV\`tl�wy/
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 a
Set Backs Electric Bond Qf
Footings Main Drain
Bond Beam Approval to Cover
Equipment Location
Underground Electric �rj<
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 Y
J.
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)