9902-132 (SFD) U) LICENSED CONTRACTOR DECLARATION BUILDING PERMIT PERMIT+Iz'�•`Z
I hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9(commencing with Section 7000) of Division 3 of the Business and DATE VALUATION 23J,7dlf.;N1 LOT TRACT 1 tt
LU Professionals Code,and my License is in full force and effect. / n 1. 'I((
O =) I I r9,
C.) License# Lic.Class Exp.Date ✓T
w r IVK 13 B JOB SITE
0,30;0V ADDRESS 79-3.30 tll.WAR APN 769-460-007
tO r- ,✓Date { / Signature of Contractor l 1 �l+ 'jy OWNER CONTRACTOR/DESIGNER/ENGINEER
r- H OWNER-BUILDER DECLARATION 1.7T 1{%�11.�1.1,C RJ 1'11"::r1_7;i:"1:A.. 1 0,;".:'
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's )'•(i bt�:X 9111 142.511.L7414 FRSX•i Y DIUVE
~ l0_ License Law for the following reason: 1.A QIJIN TA (_'A 912'+3 P1404NI X AZ SS034
Z_ ( ) I, as owner of the property, or my employees with wages as their sole 14 1")O
compensation,will do the work,and the structure is not intended or offered for
sale(Sec.7044,Business&Professionals Code). USE OF PERMIT I IIIIIII VIII 111111111111 54
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals Sttd�ihl:hAI%111,1 0Wfa.1.iN0 IE
Code). I..0 f A I.PLAN 'Au.%Fv-t•ER&fl A IJQE, S Nu t 1N+_t.l!0414F;-AK WALLS
c� () I am exempt under Section , B&P.C.for this reason
O C\I
N Date Signature of Owner
rn
d Q WORKER'S COMPENSATION DECLARATION
p Cc I hereby affirm under penalty of perjury one of the following declarations:
Lo H O O 1 have and will maintain a certificate of consent to self-insure for workers' CU:i1'u;%I L1014S 1 UCi'Ir3N 2,$33 00 3F
X W 4- compensation, as provided for by Section 3700 of the Labor Code, for the 1+1,1t0VIIAftu 1 W t)U SF
m J Q performance of the work for which this permit is issued. 0ARAQWC"110WI j/tt trU 41.
Q,() (�) 1 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 H permit is issued. My workers' compensation insurance carrier & policy no. are:
lqt z Carrier Policy No.
00 milr'�7ui It flv' . -inii i:. iii iu y)4 r' ► r tr' r ! t.
C3 7 " T L
g (This section need not be completed if the permit valuation is for$100.00 or less). `h,IZI<#i h E 5il�IAML+,ki
( ) I certify that in the performance of the work for which this permit is issued, C4.,NSTRC.r1:TICIN FFF. 101-(W-4194M) 31,14Q err
I shall not employ any person in any manner so as to become subject to the pt AN C)tf.("K FIT-V k IVtW,ut
workers' compensation laws of California, and agree that if I should become
subject to the workers'compensation provisions of Section 3700 of the Labor N11111AN1CA1,I'M, 101-M121-000 !Ilte;.rn)
Code, I shall forthwith comply with those provisions.1 ELf.L:CRICAL FEE 10I•-OW-420-000 5168.22
Date: /'r• 1�4� Applicant ;)�� � �'ill-
/ PLUMBING Will-, 1O1-000-419.00 5180 44)
Warnin : Failure to secure Workers'Compensation coverage is unlawful and 11 `+"IRC)T[(Z tifi(TfTnN{ T.r{r gF4t 1f11 iNN) 41-OM tie 17
shall subject an employer to criminal penalties and civil fines up to$100,000,in f+RAI)1ING 11'11 101-00042.1-000 520.00
addition to the cost of compensation,damages as provided for in Section 3706 INVV_41,1RCIt-Tii1t1J FFL 225-M-441-.142 53,220.44
of the Labor Code,interest and attorney's fees. ART IN PUBLIC PLALTS-RL7,stu 701-000-21,W(K) 5334 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, indemnify S)Fit 11TI'A(,C 0N`'.TR(T IT)N ANT)PLAN t'HW('K $9IN%"dl
& hold harmless the City of La Quinta, its officers, agents and employees. LIE55 PRE PAID 1'1`s1•S
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. TO-CAL I'FRMIT FENS I IIE N0W S.9,f*6.41
I certify that I have read this application and state that the above information is
• 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 pon
the above-mentioned property for inspection purposes.
IECEIP� DA7 ^ + BY
/ _ Eg& LE INSPECTOR
Signature (Owner/Agent) :��� ��f` ��. Date !�
INSPECTION RECORD
OPERATION j 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 7 .ol, Compressor �-
-Insulation vents
Fireplace P.L. Grills
-Fireplace T.O. Fans&Controls
Party Wall Insulation Condensate Lines
Party Wall Firewall
Exterior Lath — co
Drywall-Int.Lath —
Final
Final — 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 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 z7L
Utility Notice(Gas)
ELECTRICAL APPROVALS
Temp:Power Pole
Underground Conduit
Rough Wiring
Low Voltage.Wiring
FbRures•`
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp..Use of Power
Final i
Utility.Notice(Perm). GfJ