9910-139 (SFD) F t
LICENSED CONTRACTOR DECLARATION BUILDING PERMIT PERMIT#
� I hereby affirm under penalty of perjury that I am licensed under provisions of 4l�i9h3'J
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and DATEf VALUATION $14,33,74S �,3744 4jft LOT TRACT 797
co Professionals Code,and my License is in full force and effect. i Act
=) M. License# Lic.Class Exp.Date
� CY U.) f, / .�, JOB SITE APN
LLJi 4D✓Ut1+S.�J / CkV'3g)+.�(A ADDRESS 700 Na. Ai �i lSQfI
1 r- X .
r Z tate f r "� `' Signature Of Contractor -1�
OWNER CONTRACTOR/DESIGNER/ENGINEER
F- OWNER-BUILDER DECLARATION
r
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's '.c1'��Clw.atf} 1. t „'LIi*IiL�tS.�'t'� L} � ' s
C/) License Law for the following reason: 1,�1(�I)t<hl`M (:'A 97 2yA Nf�t.;1.i'Nlx A $`+41=�
Z_ ( ) I, as owner of.the property, or my employees with wages as their sole 41602►9_+l.16.56
compensation,will do the work,and the structure is not intended or offered for
sale(Sec.7044,Business&Professionals Code). USE OF PERMIT 6
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals SI1 iL 1" ){�' �3Vi {"L1tt`
Code). &Z-0-LOT u.PLAN I1'EitiY ff DOES 1401'TtsCTUM.UO(N.WALL Off?
() I am exempt under Section B&P.C.for this reason
O N Date Signature of Owner P00L,
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2 < WORKER'S COMPENSATION DECLARATION
,• p 2 Z I hereby affirm under penalty of perjury one of the following declarations:
LO H O O 1 have and will maintain a certificate of consent to self insure for Workers' GLi.Sx�y;�S C't�itir„'S2Eh"3'I�iN �',$33.Citi +
X W compensation, as provided for by Section 3700 of the Labor Code, for.the P 0E$.rL:-WPA'II0 a30.0SF
mJ Q performance of the work for which this permit is issued. i,ttr1lt�t}E:tLsr+;Fvl �Yt� 3"r3.lsG y3
Q I 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 thisLO
+
H permit is issued. My workers' compensation insurance carrier & policy no. are: y
Z Carrier Policy NO.' a' p t��t. fy g Y ,�w +?AW
00 �s4tis.CONTANY�r�j.� Fi j�1r .>e0l g l�ek� 6a o..V�gh4 cY�(�+ ti A.to IT �Y.0.i� a/Rai.
rCY
Q (This section need not be completed if thepermit valuation is for$100.00 or less). 6181RMi,I r,k"
`U-1MAR Y
J ( ) I certify that in the performance of the work for which this permit is issued, co'NsirRlfC"I'ow Wi-►:vI0418-000 S�?,YI t Sit
1 shall not employ any person in any manner so as to become subject to the V LAN;•;WUX FV It;l-f NLO(�r�;�r9.�'�8
workers' compensation laws of California, and agree that if I should become !b1ECITA Cr°L FEX $1()1.'x0
F
'ect to the workers'compensation provisions of,Section 3700 of the Labore,I shall forthwith comply with those provisions. ELHC'10CA,I"FEE' Ie: j' '" :`r Applicant /w -- " Y°l,.ifPAk5:f1�1i3FE,I
Warning: Failure to secure Workers'Compensation coverage is unlawful and 81NO f('''M41f(r3►�TY¢,F-R�''�I�' 10 149'0-241 g,`337
shall subject an employer to criminal penalties and civil fines up to$100,000,in lQItA.IN. STM _00041.2-000 $20.00
addition to the cost of compensation,damages as provided for in Section 3706 iAtV'J,0i4-A IMPACT TEE 4.1,907.0%)
of the Labor Code,interest and attorney's fees. A Wr fN k°t3BLIC KfI (%,S-ls�F Q,'701-600-:255-dIi}U
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 °81,M-7:7M.,C`,�E;9t+d��i,)�,>?.f!"`'j'''10N A�]�1'j'Y,-AN f�HEC;�', t4 7'S�,g7
& hold harmless the City of La Quinta, its officers, agents and employees. LESS, PRE-PAID
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. 10TAIl.PERMUT F.UES DUENow _ S4,11U.97
I certify that I have read this application and state that the above information is 11111111 VIII III VIII IIII _
• correct. I agree to comply with all City, and State laws relating to the building 72
construction, and hereby authorize representatives of this City to enter upon _? IE
�th/ebove-menticnecl property for inspection purposes.
"'- A
RECEIPT DATEINSPECTOR
ignature (Owner/Agent) '—'"y Date ✓ ft '
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 AWY Exhaust Fans
O.K.to Wrap _2=3 F.A.U.
Framing -.2- /,� 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 I Gas Piping
PLUMBING APPROVALS Gas Test
Electric Final
Waste Lines 22,1 _ 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)