9902-133 (SFD) LICENSED CONTRACTOR DECLARATION BUILDING PERMIT PERMIT���y���
I hereby affirm under penalty of perjury that I am licensed under provisions of
F— Chapter 9 (commencing with Section 7000)of Division 3 of the Business and DATE VALUATION LOT n TRACT n i
04 Professionals Code,and m License is in full force and effect.
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C � ch License# y Lic.Class Exp.Date
d u7 1 JOB'§ITE` ,, ]APN
r W 1� ;1 B (ONO ADDRESS M370 tit HAR 76.0.4e0-007
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Z r-- Date L,177 *=A Signature of Contractor �� "�� OWNER CONTRACTOR/DESIGNER/ENGINEER
F- cC) J OWNER-BUILDER DECLARATION PUT 11{,NIIE`S 3 11C 4:1 i 11`IL'�;;," *,(�!f�.fL'..1T
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor'sV ��bili 1v23 .ZLPaIVr!tSl'1'eDE
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~ N License Law for the following reason: L.A.QUINT.A, CA 91253 PHOENIX .AZ 85034
Z ( ) I, as owner of the property, or my employees with wages as their sole. (E+O217�7-IfCSti f F3T,-4 4990
t 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
contractors to construct the project (Sec. 7044, Business & Professionals SWt,111X FAMILY L1)ViliL..L,.1NG
.'. Code).
C () .I am exempt under Section , B&P.C.for this reason LOT 1.'.,PLAN 113. all)-RERN11T U':�5 NOT IAI�,d;��t�131..C�K Wt11.L:;
-0 N Date Signature of Owner OR 1'Cf
rn
a Q WORKER'S COMPENSATION DECLARATION
�p.� Cc I hereby affirm under penalty of perjury one of the following declarations: ,
H.O ,( ) I have and will maintain a certificate of consent to self-insure for workers' ["USTOAd CONJ'tr1.UC ONI 2,4110-00 11;171
X W LL compensation, as provided for by Section 3700 of the Labor Code, for the PC:rJtt }1 PATIO 112,00 S3-
_J-_J performance of the work for which this permit is issued. C¢AkAc3,Li1t"fl[Z1Y:1.tt'3' 626.0 St'
Q'U ; ( ) I have and will maintain workers'compensation insurance,as required by
pU;Q Section 3700 of the Labor Code, for the performance of the work for which this
U-) F— permit is issued. My workers' compensation insurance carrier & policy no. are:
Z Carrier Policy No.
STATE FUNID 035-90 12.170 M T IMATED CEI,Y'f OF!ONS'FRU PION,
Q (This section need not be completed if the permit valuation is for$100.00 or less). PIFAAIf�'' SCINI-MNr
.J O I certify that in the performance of the work for which this permit is issued, CONSTRUU1"1ON WE 1011-{1( _4 J84X)O SQ)140i
a I shall not employ any person in any manner so as to become subject to the 1111A;+iFF,F 5.'A
workers' compensation laws of California, and agree that if I should become NMMAtNICM.I )01-NO 42I-(700 v1n5 00
rel subject tb the workers'compensation provisions of Section 3700 of the Labor
Code,I shall forthwith comply with those provisions idXC1'Ifi3(�A1,1'FE I01-000-420.000 S1=i6A I
Date:',_-A ti `; Applicant �l 10-_. RLt3A 1N43:t%kis 101-MO-419-000 31$0.5111
( Warning: Failure to secure Workers'Compensation coverage is unlawful and TC'
/ f`Y`� `'1FfSN� �'' F�`1n ( F"f?[)t1-2A3-�t3f1 f"20")2
shall subject an employer to criminal penalties and civil fines up to$100,000,in 01Lr\DW(l F11: 101-000.423.000 31.10.1u)
addition to the cost of compensation,damages as provided for in Section 3706 .1NFk"'1'1t11C,''.1.'lAU Fhii 225-pail-443-34 U.fAl5.3(i
of the Labor Code,interest and attorney's fees. AW.V 1N f libLIC411 AC'E.w,-fl.[+,KU"70 t-OW755-000 S'tifi5.�33
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 St.JR4DTA'I CO?'d=UYvil ON AND P1,AN P'I J VC K $7,2072-88
& hold harmless the City of La Quinta, its officers, agents and employees. L E.3S PRE--P/kJD FT"E a $0,00
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. FCAI< `�� fj+ '%L'- 1)11T1+;NOW S7,2402.0
I certify that I have read this application and state that the above information is I IIII II VIII III VIII IIII
• correct. I agree to comply with all City, and State laws relating to the building 51
construction, and hereby authorize representatives of this City to enter upon IE
the above-mentioned property for inspection purposes.
RECEIPT DATEBY 'V DATE FI LED INSPECTOR
� g'nature (Owner/Agent) y`?! .r. Date-/
VS
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 (j255 Exhaust Fans
OX to Wrap F.A.U.
Framing ^( r .. Compressor _
Insulation Y— Vents
Fireplace P.L. Grills
Fireplace T.O. Fans&Controls
Party Wall Insulation Condensate Lines
Party Wall Firewall 41-
Exterior Lath
Drywall-Int.Lath 4
Final — LG
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 /-
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) -- /_evej