0002-404 (RPL) LICENSED CONTRACTOR DECLARATION BUILDING PERMIT PERMIT#
I-II hereby affirm under penalty of perjury that I am licensed under provisions of INI�4ltb
H Chapter 9 (commencing with Section 7000)of Division 3 of the Business and DATE VALUATION KTIT,M}t1.Ot! LOT TRACT 23N7
c� W Professionals Code,and my License is in full force and effect.
�/�
License# Lic.Class Exp-Date
W U.) 0 �� IS �j Ute i�� JOB SITE
ADDRESS J9-00AL.t�jAR APN 769-460-609
t- %
oZ Date Signature of Corf factor '� OWNER CONTRACTOR/DESIGNER/ENGINEER
cp Ot�j r r�.It n �•ra t►:r rrr r�rJ•
OWNER-BUILDER DECLARATION ` ` i'
"
W U P�)&JiX 810 1423 E. l.IhiMRSI T 1 DRIVE,
Wl1 I hereby affirm under penalty of perjury that I am exempt from the Contractor's I,A QUINTA CA 92253 PHOENIX AZ 8034
Cf) License Law for the following reason:
Z ( ) I, as owner of the property, or my employees with wages as their sole ffin2l?S7-I[t5ri C'RT.ft 1t
compensation,will do the work,and the structure is not intended or offered for
sale(Sec.7044,Business&Professionals Code). USE OF PERMIT
( ) 1, as owner of the property, am exclusively contracting with licensed 110t 11,ANi)iuk*,jPA
contractors to construct the project (Sec. 7044, Business & Professionals
Code). ilt.)OL&bPA UN0-ALARNitviiARRiOcj SHALL BE'IN Pi ACh At'P-Rh
C O I am exempt under Section , B&P.C.for this reason Ni,ASt'hFt !!v5)'EC7110N
N Date Signature of Owner
ON
a)
CL
Z WORKER'S COMPENSATION DECLARATION
C:) 2 Z I hereby affirm under penalty of perjury one of the following declarations: r
LO
H O O 1 have and will maintain a certificate of consent to self-insure for workers' 'rx AiYii/��Tt SPA f(10�'If+,(Ky LS
X w Y= compensation, as provided for by Section 3700 of the Labor Code, for the
O � Q perforrna�e of the work for which this permit is issued.
M QU •(� have and will maintain workers'compensation insurance, as required by
O S'�ection 3700 of the Labor Code, for the performance of the work for which this
Il rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
cw = Carver INS C014g'AtNy nr, T Policy No. `XDG:?T)04 49) ENtIMIFETED(M.31 O1'CL;R:Y•.'.ZIJC ION EiI.RUtt.4,'i�
O (This section need not be completed if the permit valuation is for$100.00 or less). !'h't114T1 f lw�l!,M,SEiiviiviAKi
( ) I certify that in the performance of the work for which this permit is issued, PLAN CHECK NEF lffl-000-439-318 $^+f,os
I shall not employ any person in any manner so as to become subject to the (ION tTKtrl'1110N Pr-17
tQt-1NYi..i►R-11I)f? Rt t rMl
workers' compensation laws of California, and agree that if I should become NIXI 1'T Z -I`OOL 101.Opo. 321 WJ
3 P
subject to the workers'compensation rovisions-of'Section 3700 of the Labor CELL OtiCAt.FL-j- -- ouL i01-000420.000 $4N.ou
P
Code, I s all fo hwith comply with those,prov`i ons. ,-'
Date: r APPlicant % -_' /� !'i.tJMEilNrsf{kT?--lu;N.+f_ If}I-UUU�tf9-I1U0 t2'1!r(r
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 ,
addition to the cost of compensation,damages as provided for in Section 3706
of the Labor Code,interest and attorney's fees.
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 Sf 1R:f1-irAI.('QlS4.S R1 f('E'1f)N ANn PIAN l•ti17CK ORryhv 01%
any permit issued as a result of this applicaton agrees to, &shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees. L1a.; PRE n.°JD FITS, $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 T0T'A1,'VFH11+ I1'T.'T+;p;NS IMF NOW $289.0N
permit, or cessation of work for 180 days will subject permit to cancellation.
1 certify that I have read this application and state that the above information is IIIIIIIIIIIIIIIIIIIIIIIII
• correct. I agree to comply with all City, an' relating to the building 61
construction, and hereby authorize representatives of this City to enter upon IE
the above-mentioned property for i spe {ion purpgses. -�
RECEIPT DATE BY' DAT INA rv�rtGTOR
Signature (Owner/Agent") -Date Y'e
w
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 8 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 —G�
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 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)