9902-0134 (SFD) LICENSED CONTRACTOR,DECLARATION PERMIT#
U + I hereby affirm under penalty of perjury,,that I'am licensed under provisions of BUILDING PERMIT
F_ , Chapter 9 (commencing with Section 7000)of Division 3 of the Business and DATE VALUATION LOT TRACT ? u
w . �� q Sz .z.73�. fi1 1., ;.117.7
N Professionals Code,and my License is in full force and effect. 4
&=) ch License# Lic.Class Exp.Date
W U ±'w U.) JOB SITE
T3 fAl3()+00 ADD ESS 71-360,t�.,t�,IMR APN 769-460-007
Z t— Date C 't�� J�� Signature of Contractor ��/�� t.��� OWNER CONTRACTOR/DESIGNER/ENGINEER
F
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i, ID II-
( OWNER-BUILDER DECLARATION , v +VJ
LV WI hereby affirm under penalty of perjury that I am exempt from the Contractor's ? -� �1� '42 E.U NIVERS11T DRIVE
~ N License Law for the following reason: LA,()f_ltNT A CA. 9225 A PROUNIX AZ X5031
Z ( ) , I, as owner of the property, or my employees with wages as their sole ((�{)2 2i7-1ti�tt C.BLY iM
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 111111111111111111111 III 49
contractors to construct the project (Sec. 7044, Business & Professionals ' s1NCIL hr� f11� CJl a,.i.lJ4li. IE
Code). `l — -— — —
co i„is1 o.Ni siJv.3FJ(;,iva7-�sLtiitivli t,t+u : .NuT INCLUDE/ .Ck,- ,'C ALU
• () I am exempt under Section , B&P.C.for this reason
`N Date Signature of Owner +:a4t l'iD0L.1�LAN(!•flws`14 L'Fk£2113!UC`) 1:)75%FOl2,tvtiJ}..'fift i,iS iSSUt"Cl c;,£,'
U rn SAM6 PLA14'I"5'P
a Q WORKER'S COMPENSATION DECLARATION
lO Q.Z I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a certificate of consent to self-insure for workers' '" 11 ^ ' .,
U)
F- O ( ) �:'v;�1'�.:.� +:;tiid�i�'FiU4-""C2JtV .:,,f,3+.1.0,,3
X W compensation, as provided for by Section 3700 of the Labor Code, for the 1?t;fiC;Fftl'6�'1:iC:+ 130.00 SF
O-� Qperformance of the work for which this permit is issued. QARA(0(:A.141'0k1T 5780)SFm Q.U %P) 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
d I— permit is issued. My workers' compensation insurance carrier & policy no. are:
•Z Carrier Policy No.
00 a 'it i 1�UND U3�^313.,J.? i .'�l a 1�$f�.x M x;11'ST OF CONSTi i�UICT SON 0 .7441.50
�.O
g (This section need not be completed if the permit valuation is for$1,00.00 or less). 13'E.R1��l� i.+:SUMMARY
( ,) I certify that in the performance of the work for which this permit is issued, G;r�)ldli'1'Rl£("£TON 1.EX 101"000-419-000 Sf,10ki.�J
I shall not employ any person in any manner so as to become subject to theI,p AJ3f"i >� i� 1�1-0U-d30.3jf1
workers' compensation laws of California, and agree that if I should become
'subject to the workers'compensation provisions of Section 3700 of the Labor i1�UXIIr1tNIG't1J,T JX 101_300-412I_000
y3 Code, I, hall forthwith comply with thosQ�proyisionO 1.S W 1RICli1.,1�EL 101-OW-420• x()() 3165.24
!Date: �7�//A7 7 Applicant /7/1�� !X" �.-. �'£:UNHAING'3 FLE 1.t)1-Ut�1-1?1 J-000 sing.10)
Warning: Failure to secure Workers'Compensation coverage is unlawful and 87 RONn Mo TiOH Frv,-1Rj',t[f) 101.4)(MI-241_00(.) 112.1,17
shall subject an employer to criminal penalties and civil fines up to$100,000,in G1trD.tJN.fEt $240,01)
addition to the cost of compensation,damages as provided for in Section 3706 M RAST,RtJU"£MC,FE F 225-000442-342 443.342 $5,224.44
of the Labor Code,interest and attorney's fees. AIG'IN Pl3£3LIC PLACES RE31B 701-000-25,E-000 $334.37
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 81.IR-)TA,1,C;OMORl iU1'ON AN PLAN C`iM3'7 �7 nth<Nl
& hold harmless the City of La Quinta, its officers, agents and employees. 3,F SS 1'R1's-l'1 D 1' 1~S TrQ.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.-�.A�+ � �. ilr:�{DUE�CAVtI7.3R(>!!1►
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 upon I !'�1j'�
the above-mentioned property for inspection purposes. i FAY
y !' RECEIPT DAT BY ( S DAT ALE / INSPECTOR
Signature (Owner/Agent)��1r'«'Y , •�1�� Date� �r �� r/
f
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&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
Footings Main Drain
i 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_ - - Z- 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 d
Final i
Utility.Notice(Perm).', fr