9912-010 (SFD) LICENSED CONTRACTOR DECLARATION PERMIT#
U) I hereby affirm under penalty of perjury that I am licensed under provisions of BUILDING PERMIT "I"10
+— Chapter 9 (commencing'with Section 7000) of Division 3 of the Business and DATE VALUATION $214,$55"O LOT 7 TRACT
UU.9 Professionals Code,and my License is in full force and effect. b,
License# Lic.Class Exp.Date
r-- C) U*),3 6906 w c�nQ{i0f JOB ADDRSITE ESS ""420.f�AHAR' APN 7-39-40- *8
LLJti
oZ ate l ' '" ���j Signature of Contractor _✓ OWNER CONTRACTOR/DESIGNER/ENGINEER
,. co :,P� HJ:�9 ES I mo:. R i S'iF34'�'`aM 'T, INC:.
D H OWNER-BUILDER DECLARATION
.00 P,O L �.i.t3 1425 P;.t3bIr;'VCFiti.l'd"y J'PAYE
UJ W I hereby affirm under penalty of perjury that I am exempt from the Contractor's Ul NTA CA r. WCAZ 5 ,
License Law for the following reason:
Z( ) 1, as owner of the property, or my employees with wages as their sole (x~07)2.57'16'5 CRLA 49W
compensation,will do the work,and the structure is not intended or offered for
sale(Sec.7044,Business&Professionals Code). USE OF PERMIT '
(' ) I, as owner of the property, am exclusively contracting with licensed SWOLE FAMiLV i,.WEL1. NG
contractors to construct the project (Sec. 7044, Business & Professionals
Code). ST'S✓'•-LOT 7,-PLAN 2AR-140 tii.Ox"K WALL OR;POOL.75%R.EDUCTiON.
() I am exempt under Section B&P.C.for this reason ON y>}y N C-flECK tt:.hk--. ISSILIAN X UW_,WA.- :;}'�.HN.
Date Signature of Owner
' p rn € EISL'ACEUTP`ft`3v_Tl_'4 �=110.140(OiANGE O..F P.LAN'T1'1 Q,__
Q WORKER'S COMPENSATION DECLARATION
C:) Z I hereby affirm under penalty of perjury one of the following declarations:
` � p O 1 have and will maintain a certificate of consent to self-insure for workers' f'( ivl �Of�' C jC�ti 2.5 111F
X w compensation, as provided for by Section 3700 of the Labor Code, for the P'0,RCff11P io 203.06 Sri"
O._ Q performance of the work for which this permit is issued. �CX��itA(31JC Aft?{faf %2.00 61*
M Q U ( I have and will maintain workers'compensation insurance,as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
rn permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier , Policy No.
ob 5 Pa.S.COMPANY OF 1' %A rbT w9lit1
i.�'�$a"P�A�T.`'►?f t3`s, 4'f.E+ �,a�ti�3���[}Q".�[�2�d 2`�$��i�.���
OQ (This section need not be completed if the permit valuation is for$100.00 or less). I' 'RX ; 'i'[It►riW1'
J ( ) I certify that in the performance of the work for which this permit is issued, CONS'IRUk"TION FEKE jEt! fiUrJ-4f)S>'i4)s' S1,042,(K)
I shall not employ any person in any manner so as to become subject to the K,AN( H. CX FT-T,. ';Vd;47
worker compensation laws of California, and agree that if I should become AWC'PWQC'A1_F7;1: 100_000-411211-000 Sj1a.50
Fate:
'ect to the workers'compensation provisions,of Section 3700 of the Labor ECT&ICAJ;FL78' Rf}t,•{ -X20- � S1yy
e,I shall fo,3F*,ith comply with those p,r9vision , ° ',�-4-,' '�r Applicant G-- "� PLON01ING ti EF f,(3!=!}OfY-dl.4�-(}{JE? $180..
777()Arel NK)Tlow RE7_R SA) 101_t}(1t?-211l-(" S21-49
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 0.lAC81N0P L 1()1Q0042MOO
addition to the cost of compensation,damages as provided for in Section 3706 i'?isW-9.01.11 N !AIPALT!'"iii Sf.9a%•(?iD
of the Labor Code,interest and attorney's fees. Ab',,T fN 1110MAC 1,11,.AC'i"S-RESIC 701-000-2554M $x'7.14 ;
IMPORTANT Application is hereby made to the Director of Building and Safety J f
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 SUB-7S� AT,CIONS�'UC' t� )AND V1,A_ t,'j�(i 1C. �'� t!��si}R3 4A �
& hold harmless the City of La Quinta, its officers, agents and employees. �•,I:S� .�1�9?-z",�il�1 1.�S $0.010
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 'T(A.'Ail*411RIMIT FEIN DWIR.NOW S 3 943.44
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 r9 I IIIIIII I III III III III 69
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 ; IE
the above-mentioned property for in pection parobses. ti
/ RECEIPT DATE BY DTE FI ALD INSPECTOR
Signature (Owner/Agent) -''� � Date '��' ��� a'
INSPECTION RECORD
OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR
BUILDING APPROVALS MECHANICAL APPROVALS
Set Backs - Underground Ducts
Forms&Footings Ducts
Slab Grade Retum Air
Steel Combustion Air
Roof Deck G(/ Exhaust Fans
O.K.to Wrap Z"23 GC) F.A.U.
Framing 0</ Compressor
-. Insulation GCS 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 /a2=`7 / A&IdPOOLS - 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 - _(fOlt_ 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 l k
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 (4—M/
Utility Notice(Perm) _G'�