9910-141 (SFD) r
LICENSED CONTRACTOR DECLARATION PERMIT#
I hereby affirm under penalty of perjury that I am licensed under provisions of BUILDING PERMIT4T-# tl
f— Chapter 9 (commencing with Section 7000)of Division 3 of the Business and DATE VALUATIONZ4° �; � LOT TRACT dFS77
C14 W Professionals Code,and my License is in full force and effect.
0 :) ch License# Lic.Class Exp.Date
JOB SITE APN
ti LLJ O 4) UQA B ,it �: Ouil 20! ADDRESS 79-�I1I1,t!'t',,r�FUR 701%460-4108 �
� f J
r Z1`1 ,Date '�` SignatureofContractor /- OWNER CONTRACTOR/DESIGNER/ENGINEER I,
O s
7 +v{
co r s,r3°.110011:^1,Z,r' o St It°'�t`'4 f� 1:'�19+5 MIC.
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C:) OWNER-BUILDER DECLARATION " � "'• ` ° ' "° ` � "° �''" ` t
L J W I hereby affirm under penalty of perjury that I am exempt from the Contractor's A }
~ d License Law for the following reason: LA QU(NITA f-A 92253 PI-J�?ENIX Apt. M14 I•
co ( ) .I, as owner of the property, or my employees with wages as their sole l2�: 7-1fi:5�1 t: 1.t1 .1 ?
compensation,will do the work,and the structure is not intended or offered for
sale(Sec.7044,Business&Professionals Code). USE OF PERMIT p
( ) I, as owner of the property, am exclusively contracting with licensedA
contractors to construct the project (Sec. 7044, Business & Professionals SINGLE' 1.9W7RT,1Ntar
Code). SIR)-LOT F;,PLAN La.�'.i_i3V"i I)(jE N if IWILUD£L!f 6CK WALL OR
ce) () I am exempt under Section B&P.C.for this reason I•
N x�t.!(el,.'IS'Sb.•{.Li:)L+�;:'•i1014 C*PLAN�.,titFs�;TC.1;E11,FOR A1l I:TJP1,T1 ASSUA,NC,1:
Date Signature of Owner
Q WORKER'S COMPENSATION DECLARATION
CL
C:) 2 Z I hereby affirm under penalty of perjury one of the following declarations:
LO � �'i O O 1 have and will maintain a certificate of consent to self-insure for workers' ST'UM C O i,;I,X19"f.`001 2157<.ory 011
X W LL compensation; as provided for by Section 3700,of the Labor Code, for the P0R..;EfYA.!10 203,(K)OF
O � Q performance of the work for which this permit is issued. �Frel�Al�ivt�riicft�Tti �SFm Q U (Nf 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
0 Z permit is issued. My workers' compensation insurance carrier & policy'no. are:
Carrier Policy No.
cb nIli�.CC)VAiNY O.'+".1` �1i DH11La l 1900- 01'IN1,410:c.�COST OF(,�ri'�STREC-aFi TOA
Q (This section need not be completed if the permit valuation is for$100.00,or less). P�• 11a SUAINURY
J ( ) I certify that in the performance of the work for which this permit is issued, CGNV!';itEbQ;NV_Y'N FEY lmiw
I shall not employ any person in any manner so as to become subject to the P(.,ATf('f a•P,,Ck 1T11 E(11,.0(10-414-318 5114,47
workers' compensation laws of California, and agree that if I should become Tvdrl hlAlailf,:A1, 3 101-000-421-000 $111.50
sleet to the workers'compensation provisions 9f,Section.3700 of the Labor
3 Code, I shall forthwith comply with those proviseos. •r1:Ci,Tu(;r13_I.T.L' 91?1'tZC1CI•.rd C){? $159.31
date: 1•/''f ��P' Applicant / i»t.U-MBINGi EX !01-000-419-000 $180:5
Warning: Failure to secure Workers' Compensation coverage is unlawful and S}c�c»C,�df;�'IC+N ITE-RFS13 101-��'��f Opft $�F �}y
shall subject an employer to criminal penalties and civil fines up to$100,000,in GRADING FEE 101-M-423.000
addition to the cost of compensation,damages as provided for in Section 3706 ))6-,VELi'1#'M i1&A0'M
of the Labor Code,interest and attorney's fees. AXV 114 t'tlKIC 1~T.At,`1:3-RL:`:11','7044(K)�-25— CC3t3 f4
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 F_�•TOYI AV_''ON�7?�I_f11-l" O`AND`i'IAN I C
& hold harmless the City of La Quinta, its officers, agents and employees. LE',SS PRE-PAiT.}FEES $000
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. 'f,f3TAL PERMIT VE ES DUE NOW
1 certify that I have read this application and state that the shove information is 66
• correct I agree to comply with all City, and State laws relating to the building J` . IIIIIIIIIIIIIIIIIIIIIIIII
construction, and hereby authorize representatives of this City to enter upon ��Y IE I'
the above-mentioned property for inspectio urp'oses. - l
RECEIPT DATE By/ D N(A1LE INSPECTOR I.
S� ignature (Owner/Agent) Date
,
INSPECTION RECORD
OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR
BUILDING APPROVALS MECHANICAL APPROVALS
Set Backs -/ LG( Underground Ducts
Forms&Footings Ducts
Slab Grade Return Air
Steel Combustion Air
Roof Deck Exhaust Fans
O.K.to Wrap _ c,,J F.A.U.
Framing L W Compressor
Insulation 2 4- --3- 'Z Vents -
Fireplace P.L. Grills
Fireplace T.O. Fans&Controls
Party Wall Insulation Condensate Lines
Party Wall Firewall
Exterior Lath �4 . (�
Drywall-Int.Lath
Final -l�_ Ud
Final - r� POOLS - 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 - j Heater Final
Water Piping Plumbing Final
Plumbing Top Out Equipment Enclosure
Shower Pans O.K for Finish Piaster
Sewer Lateral Pool Cover
Sewer Connection Encapsulation
Gas Piping
Gas Test _ C.)
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) &- "