0002-0406 (RPL):i ^ LICENSED CONTRACTOR DECLARATION BUILDING PERMIT PERMIT#
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'f 'I eby affirm under penalty of perjury that I am licensed under provisions of 19iii02-41116
1— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and DATE-7/�,
�� ?J VALUATION S10,Ilfiii./ii) LOT 7 TRACT 7.819'I
c� W Professionals Code,and my License is in full force and-and <
License# Lic.Class Exp.Date _
(y fy45 . I3 /li1Jl�20t JOB SITE ADDRESS
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6 Z r- Date --- �' Signature of C no tract0 � � —OWNER CONTRACTOR/DESIGNER/ENGINEER
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r- H OWNER-BUILDER DECLARATION .+�.,.. : .....�.. ,. . . . v+..va.o.+,i.+.,•,.�.
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d I hereby affirm under penalty of perjury that I am exempt from the Contractor's LA QUINTA CA 92253 PRIDEN1k AZ 8:5034
License Law for the following reason:
Z_ ( ) I, as owner of the property, or my employees with wages as their sole ('6021257-t�tir; C;f31.f 4990
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 PCPA,AN ii)k SPA
contractors to construct the project (Sec. 7044, Business & Professionals
Code). 1!OOL&ut+A ON`i.V-A1.M2iviSii3AR1AJDRS S3 ALL BE iN PLACE AT PRE
CO () I am exempt under Section , B&P.C.for this reason 1'1.r1.S'1 tilg 1N:i€�1iC."1'1C N
N Date Signature of Owner
ON
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Q WORKER'S COMPENSATION DECLARATION
CL
C) 2 Z I hereby affirm under penalty of perjury one of the following declarations:
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O O 1 have and will maintain a certificate of consent to self-insure for workers' ;^04�a,,llv",3itr,R 5,1>A IU,l1gG.G0.i.s
X W LL compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
m Q U ( � have and will maintain workers'compensation insurance,as required by
OU Q Section 3700 of the Labor Code, for the performance of the work for which this
Il LO H permit is issued. My workers' compensation insurance carrier & policy no. are:
oo z Cartier IN:.,COII<^u'A?+l�l t?.f''1 Policy No. '99.11004,MI(X) PST11 c `T^ + IN I;IUC r►��� 1�
�' t "i1'�TT?t? 1 a 3G;�
OQ (This section need not be completed if the permit valuation is for$100.00 or less). PERMIT FEE aJllYll:1,3ZI
-� ( ) I certify that in the performance of the work for which this permit is issued, FLAN(H'F_`a.K FEF 101-000-439-3113 S76,US
I shall not employ any person in any manner-so sas_to become subject to the C`ONISTRf1< 1014FF.1 1011-i)M-411;C.f10(! S117,fkf
workers' compensation laws ofJCalifoinia, andsagree that if I should become mmntuckcfll:jmf s-_rooL .f1;-0100 41-0w Eyt,t)0
subject to the workers' compensation provisions of Section 3700 of the Labor
�r s ori ELE,C,1RJ.i:AL FEE--POOL i.01-00-120-000
.Code, I shall forthwith comri ly with ,ose,provis ons. ; -
b`ate: 7�'�9A41 Applicant ��� 7) � I'Ll{M(3fNt.ikts'tI- k'C:►cIL l01-1}UU �llu-()f)() �3?.�)l3 ? ?
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 t.a
addition to the cost of compensation,damages as provided for in Section 3706
of the Labor Code,interest and attorney's fees. �•f 't r
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. t � E
1. Each person upon whose behalf this application is made&each person at J
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 Sf�1�-'t'Q't'�1j (_t.)�j`"!'!2t ifjfl?�I AND Ri.AT;;d'ffR,f�fr' f'Tfn!(1t
& hold harmless the City of La Quinta, its officers, agents and employees. L.' fi .P1Z -PaI13 Lf..; w1.00
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 '1' YAJ,E•9k MtIT',4 F 3+;,5i DUE NOW.
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and staff that the above information is IIIIIIII VIII IIIIIIIIIIII 68
• correct. I agree to comply with all City,'and Sate laws relating to the building r
construction, and hereby authorize4representatives of this City to enter upon *� /� IE
the above-mentioned propertyfor inspection,purposes. ' - --
RECEIPT DATE BY 1 4/ DATE FINALED INSPECTOR
\Signature '(OwnedAgeny '� �� -Date, � t I
INSPECTION RECORD
OPERATION DATE I 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 :• Ccf
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)