9910-142 (SFD) I LICENSED CONTRACTOR DECLARATION PERMIT#
I hereby affirm under penalty of perjury that I am licensed under provisions of BUILDING PERMIT 9910.142
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and DATE VALUATION LOT TRACT
N �;� 1,74�t ?,477
c� W Professionals Code,and my License is in full force and effect. 1
License# Lic.Class Exp.Date `
Lu
JOB SITE'
O 695 ,•' 061300i ADDRESS 79-4063iAalAA
Z 98ie �• �'"� Signature of Contractor OWNER CONTRACTOR/DESIGNER/ENGINEER
i' (D OO SJ:1•[/.aJi� �.i 6+3�. 1t�4 INT Y ..l l�►i.1 ,+ +9�cf.V�.
J
I.-
Cp OWNER-BUILDER DECLARATION r
W w I hereby affirm under penalty of perjury that l am exempt from the Contractor's
P.0 SOX SIG 1425&i��E�t' s����7;°Y DRTV iF
F- 10_ License Law for the following reason: LA QUINTA Ok 421.2151 PRO DI I� A7 85-0-14
Z_ ( ) I, as owner of the property, or my employees with wages as their sole (6M)257-1.656 C RLH 49%1
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
jhiLa�:
contractors to construct the project (Sec. 7044, Business & Professionals
CY) Code). D-LOT 9,PLAN.3,PERM DOES-NO""I'M'f:ME BLOCK`tl+ilil OR
LO () I am exempt under Section B&P.C.for this reason Date Signature of Owner 4s*L.��'5 ;y 12L�s1)Uf,11UPi{J PLAN G t'7S 1�Fi;�tai?shltlf.7'It>Lfl.ttiw ClA�Ir:L
OF SANW, PLAN TYPE
L)
Q WORKER'S COMPENSATION DECLARATION
C) Z I hereby affirm under penalty of perjury one of the following declarations:
LO - O O 1 have and will maintain a certificate of consent to.self insure for workers' C"crS"C3"rvl{�r'f J;iIIZLh.`T1.=Ir' 3%.0 S` '
X W compensation, as provided for by.Section 3700 of the Labor Code,.for the r°oR4,,tif8 Arxo 130.W SF
O J Q performance of the work for which this permit is issued. M` 578.00 8F
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
Il 0 Z permit is issued. My workers' compensation insurance carrier & policy no. are: 4. a
Carrier 'Policy No.
00 � ZN.S,COMIVr'�.Nri r✓F i gal-JT-17t'04190, �L��r araer��i�;��l�+fin E'r$ ����iaek�a.'a��ii1 2233•74�r&°.►rdr1.
Q (This section need not be completed if the permit valuation is for$100.00 or less). PERMIT FEE.S$31dMARY
J ( ) I certify that in the performance of the work for which this permit is issued, CONS'3'RUC;TIONTFRE 101-f,100-41S-OW 4.t,Rr3:�,5ti
I shall not employ any person in any manner so as to become subject to the u1,AWC: d?r.k`,TVF ttiF-fI('•(t-4 `3 7i
workers' compensation laws of California, and agree that if I should become l.r., 'i1i11 ICAL Val'
1 subject to the workers' compensation provisions of••Section 3700 of the Labor
.`.iJ i 1 ,iicG"tEb11.AL F.l:efr -tf4lfJ�4 �-ice S1,69,«",'d
Code,I shall forthwith comply with those provisions./
date: o /A- Al Applicant— $180.$0
17
Warning: Failure to secure Workers' Compensation coverage is unlawful and '61 k{J�-d?f;4y� 4i-(N)fi `+;12
shall subject an employer to criminal penalties and civil fines up to$100,000,in {:iRAD,114Ci ITE10 "f)0{' Ix 4 }i) t3•f)0
addition to the cost of compensation,damages as provided for in Section 3706 OiX-4- .ti t>:M:INNI,!•4Cr;irhh Si,9TI".Ilk
of the Labor Code,interest and attorney's fees. 11:WF IN PU91.1C P➢..AGEZ-.40,510'101-(1(1D-2,55-OW �S'33�4:37
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, indemnity S1A1-7V?rA'GCt+ONS1"RIX-MOIN''.AMD P1,JUN 1113C'M $4,073.,16
& hold harmless the City of La Quinta, its officers, agents and employees. LE8S PKE-}AID F'1-TS a+( OO
2.Any permit issued as a result of this application becomes.null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation. 11,�-8'Ii�1,$" kL4E'8! �'i:�:d �.E#�' A1W
1 certify that I have read this application and state that the above information is IIIIIIIIIIIIIIIIIIIIIIIII 60
• 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 6 IE
the above-mentioned property for inspection purposes. '?`
i RECEIPT DATE BY D INALE INSPECTOR
Ai" ture (Owner/Agent) Date "- i/`ice%
INSPECTION RECORD
OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR
BUILDING APPROVALS MECHANICAL APPROVALS
Set Backs Underground Ducts
Forms&Footings f Ducts
Slab Grade LK Return Air
Steel Combustion Air
Roof Deck ca Exhaust Fans
O.K.to Wrap F.A.U.
Framing — 7 60 Compressor
Insulation Vents
Fireplace P.L. Grills
• Fireplace T.O. Fans&Controls
Party Wall Insulation Condensate Lines
Party Wall Firewall
Exterior Lath C�
Drywall-Int.Lath
Final
Final POOLS - SPAS
BLOCKWALL APPROVALS steel
Set Backs Electric Bond
Footings Main Drain
Bond Beam Approval to Cover i
Equipment Location
Underground Electric J
Underground Plbg.Test
Final Gas Piping
PLUMBING APPROVALS Gas Test {
Electric Final
Waste Lines Heater Final i
Water Piping Plumbing Final
Plumbing Top Out Equipment Enclosure
Shower Pans OX for Finish Plaster
Sewer Lateral Pool Cover
Sewer Connection rL� Encapsulation
Gas Piping
Gas Test k
Appliances
Final
COMMENTS:
Final
Utility Notice(Gas) J
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 a 5 –
Mity Notice(Perm) –3_ C-J