9702-005 (BLCK) LICENSED CONTRACT&DECLARATION r PERMIT# CONTROL#
(1) 1 hereby affirm under penalty of perjury that l am licensed under provisions of BUILDING PERMIT y�az-IN1�S 4 6 6 7
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and DATE VALUATION LOT TRACT
N W Professionals Code,and my License is in full force and effect. �� ' � S1,440.00
O :D M License# Lic.Class, Exp.Date ,
rJ t>x917ti C-2 0/3�?19 AooREss �iy- .yt A1riLr,�1 APN
Z N Date Signature of Contractor� .�' "' * OWNER CONTRACTOR/DESIGNER/ENGINEER
C° O rn OWNER-BUILDER DECLARATION'd MR. I:i3E3UTTAY1,011 MASON11'Y
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's 49-o41 AVl.L1.A 42-200 MACON HILL,SI#:.ii
~ U) License Law for the following reason: LA QUIN'l'A CA 92253 PALM DESMT T CA 92260
Z ( ) I, as owner of the property, or my employees with wages as their sole 2-QUI; !:'M0 1246
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
Code).
() I am exempt under Section , B&P.C.for this reason !#t ON i,1 !Jk W t 6 tN taARF)iM+rVilLar
N Date Signature of Owner
pN
O)
CL Q WORKER'S COMPENSATION DECLARATION
o < Cc I hereby affirm under penalty of perjury one of the following declarations:
Hp O 1 have and will maintain a certificate of consent to self-insure for workers'
X W compensation, as provided for by Section 3700 of the Labor Code, for the
m � Q performance of the work for which this permit is issued.
Q U ;(t7)_,l have and will maintain workers'compensation insurance, as required by,
O U Q 10 Section 3700 of the Labor Code, for the performance of the work for which this
Z permit is issued. My workers' compensation insurance carrier & policy no. are:
tt Cartier Policy No.
Ob O CryCASUALTY t~OIN111 41Y.'ti1�)1"�r'1v�/i11 �s�fi"�'�i��c�"Z�w�r`1.013T OF CIONISTI UCIrlI�iN
J
(This section need not be completed if the permit valuation is for$100.00 or less). �"�;Uf1 IT I�•l'C SlilNfill'�.�11l V
( ) I certify that in the performance of the work for which this permit is issued, CCN TI1Z0'�t'IQN FEE 10 1-OW-1 I X-000 �?S.l3l►
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if I should become
3 subject to the workers'compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date: Applicant
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 fi
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 persona 1k
whose request and for whose benefit work is performed under or pursuant td.
any permit issued as a result of this applicaton agrees to, &shall, indemnify ' fAIDAI,('f)Al;�"!"OK 1'ft.N ANT'S MAN CJJ C V, ;dig 0
& hold harmless the City of La Quinta, its officers, agents and employees, LESS ITIS-PAI;r i ERS SQ•UQ
2.Any permit issued as a result of this application becomes null and void if D r� s� �n97
work is not commenced within 180 days from date of issuance of such � 7 �1 J J
permit, or cessation of work for 180 days will subject permit to cancellation. Tt)"i A4.1 PERNO T FEES Ir 1TE NOW $35.00
I certify that I have read this application and state that the above information ist 1 I� A
-f correct. I agree to comply with all City, and State laws relating to'the building r�ti"(Y OF t- ` `".t� I IIIIIII 11111111111111111 66
construction, and hereby authorize representatives of this City to enter upon ` IE
the above-mentioned property for inspection purposes:
RECEIPT DATE � �� ABY J,01 �� DATjaFI A INSPECTOR
`' Signature (Owner/Agent) �r l `"� Date > r ` l /M/� !/S
INSPECTION RECORD
OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR
BUILDING APPROVALS MECHANICAL APPROVALS
Set Backs Underground Ducts
Forms 8 Footings Ducts
Slab Grade Et�� 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
Bond Beam Approval to Cover
Equipment Location
Underground Electric
Underground Plbg,Test
Final Gas Piping
PLUMBING A P OVALS 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)