9910-140 (SFD) LICENSED CONTRACTOR/DECLARATION. PERMIT#
I hereby affirm under penalty of perjury that I am licensed under provisions of BUILDING PERMIT "0140
RFs Chapter 9 (commencing with Section 7000)of Division 3 of the Business and DATE VALUATION LOT TRACT
to SllK+1' 7 37i''U7
c� W Professionals Code,and my License is in full force and effect. � J
License# Lic.Class Exp.Date
r I LU r.• JOB SITE 791,428 j��� UR APN
� LU � t] 5 � r Vbr��k'2iK ADDRESS AZ"
UR
f
Z ate Signature of Contractor—
Z OWNER CONTRACTOR/DESIGNER/ENGINEER
1 C(OO � C- F
r� H CC OWNER-BUILDER DECLARATION R.TT}iC?1tdES LLC. RITI"AT9 ME=,TNC
L)W I hereby affirm under penalty of perjury that I am exempt from the Contractor's f:U BOX 810 1425 E.L'N1Yl:'IlSi7'l� DRIVE
License Law for the following reason: LA QUINTA CA 921-83 PHOENIX AL 85014
Z ( ) I, as owner of the property, or my employees with wages as their sole llXYI}257-1656 ('1114 •t")
1 compensation,will do the work,and the structure is not intended or offered for
sale(Sec.7044,Business&Professionals Code). USE OF PERMIT a
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals =►1lVli1�E EA1r11L� DV4`E;i.LINt
Code).
() I am exempt under Section B&P.C.for this reason )-L.
-LOTPLAN t, f'f1tJv111'iK1f 3 NOT 1t .Ui�fi HJ.CICK WALL
`O Nx.),.75%RF Kx 71c�N ON PLAN C RECK FW FkAk MULTI P11i 13,%IANCIs
N Date Signature of Owner
O rn ciF'SAME PI.AN TYPE.
Z WORKER'S COMPENSATION DECLARATION
C:) CL
2 Z I hereby affirm under penalty of perjury one of the following declarations:
U-) O O 1 have and will maintain a certificate of consent to self-insure for workers' ti LISTii31 C ONS'IRUCTION 2„470,10 SF
X w compensation, as provided for by Section 3700 of the Labor Code, for the I�:>r CIi�YN►i'iu i11.Ub.SF
O � Q performance of the work for which this permit is issued. t3AItAt3tiH.'e'1W�t.NrC'1' 616.00 SF
M Q U ( I have and will maintain workers'compensation insurance,as required by
OU Q Sec ion 3700 of the Labor Code, for the performance of the work for which this
rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
,It Z Carrier Policy No.
aoo O INNS...'ONIPANY OF T W111E,17f?w 1 (x) ESTINUMD CMT Of CM3TRUMON, 2KI72.20
J (This section need not be completed if the permit valuation is for$100.00 or less). PEPA11T FEE%.i mmlk� '
( ) I certify that in the performance of the work for which this permit is issued, (`0 N.1rI'kUC'TIUN FEE 101•A)Ol)41MA)W S1.g14.tR1
1 shall not employ any person in any manner so as to become subject to the Pi AN 0F.(`9 Ff-T, 10)-MO-439-318 3W_*.HB
workers' compensation laws of California, and agree that if I should become
subject to the workers'compensation provisions of Secti n 3700 of the Labor itilCCI1AN1CA1.>fis $105.U0
101 (lOQ `1 000
r
Cade, I shall,forthwith comply with those provisions. IRA-A1RICAL FRE 101-OW-420-M 5156.47
sate: f /4 0 Applicant :" I11.1)MBINO Flip 101-OW419-M SAWt.30
f._ u(w I t�h►'t`TON F'F•.R F 410 f 0J-lKlt !41-.tltlil %INI.F^
Warning: Failure to secure Workers'Compensation coverage is unlawful and �Ii
shall subject an employer to criminal penalties and civil fines up to$100,000,in (3ki MNC 1101-OW-423-000 %V-00
addition to the cost of compensation,damages as provided for in Section 3706 &kVI L4.)f1k t.IMPAC'C ftkfi Sl,v+07.iw
of the Labor Code,interest and attorney's fees. ART IN KA41.IC.`PLACES-KH73W 701-000-255-MSD45.15
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 SC)R=1�c"r(AI,fY3N'�TKt.I("t�nN ANI?PI-AN<'{iFf"i� t,%,877 W)
& hold harmless the City of La Quinta, its officers, agents and employees. LESS PRE-PAID FL ES 50.00
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
permit, or cessation of work for 180 days will subject permit to cancellation. 1'U'f AI. 1N�ltMl 11~'L���Y DUE NtYM/ S3,RT7.9f!
I certify that I have read this application and state that the above information is I IIIIIIIIIIIIIIIIIIIIIIII
• correct. I agree to comply with all City, and State laws relating to the building 70
construction, and hereby authorize representatives of this City to enter upon IE
Zignature
ove-mentioned property for inspection purpo eSw
�' RECEIPT DATE BY ` D T.�FI A �� INSPECTOR
(Owner/Agent) Date j '� ?
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
i
Final
Final POOLS - SPAS
BLOCKWALL APPROVALS steel t
Set Backs Electric Bond
Footings Main Drain i
Bond Beam Approval to Cover
Equipment Location
Underground Electric
Underground Plbg.Test
Final t 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
S r Lateral Pool Cover
,*`Sev4r Connection ./ Encapsulation
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)