0307-210 (TRELLIS) LICENSED CONTRACTOR DECLARATION PERMIT#
U) I hereby affirm.,under penalty of perjury that I am licensed under provisions of BUILDING PERMIT -�<�4�i
F- Chapter 9 (commencing with Section 7000)of Division 3 of the Business and DATE VALUATION °y12t2tiCp:7, 0 Lor' y`3.5 TRACT 3.Re'NE
W Professionals Code,and my License is in full force and effect.
5 ch License# Lic.Class Exp.Date
W LOi :S i Y!,13-8 n r`IC, x4311 JOB SITE ADDRESS %Q-376 t�•�'3?:.t�UIR�47 �', $.r�.MI W. APN 643-Q90.014
Z t� Date "�� '1 03'' Signature of Contractor` " OWNER CONTRACTOR/DESIGNER/EN (NEER
J U OWNER-BUILDER DECLARATION `8-40'1 10111M'a a 31 05'LAN QUMn:Al:..:A'9,T353
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's ��.FiET41Ml' !� yy Wdt f ; °�� C�i1 �� 9213C-0,
~ IZ License Law for the following reason: '�
Z_ ( ) I, as owner of the property, or my employees with wages as their sole d;�13i�' Tnt3fa s'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 03`aIMIRZAL1A33riDARI
' contractors to construct the project (Sec. 7044, Business & Professionals _ _� _ _
Code). �I.i. fi YJ eLu Fi i FYt�. ".:' Y' uv u.�. ,6,t LV . N.8 41b 3a.i'^rL' f'lYx4n7 s'3
O I am exempt under Section , B&P.C.for this reason OF V-1"
N Date Signature of Owner
OC
Q WORKER'S COMPENSATION DECLARATION
It (r I hereby affirm under penalty of perjury one of the following declarations: PORCHiP&I'10 tiF
Lo FZ O ( ) 1 have and will maintain a certificate of consent to self-insure for workers'
X Lu LL 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 () (,11) 1 have and will maintain workers'compensation insurance,as required by
O 0 Q Section 3700 of the Labor Code, for the performance of the work for which this
LO
0) H permit is issued. My workers' compensation insurance carrier & policy no. are:
It z Carrier Policy No.
Q (This section need not be completed if the permit valuation is for$100.00 or less). CCxNMUCT101,4 TEL )�!_400-4)8_000 $.A-4.00
_J ( ) I certify that in the performance of the work for which this permit is issued, PLAN CHWIX FZ 10 1"000.4ag-31.8 #7t5• /
I shall not employ any person in any manner so as to become subject to the MC."TRICAL,FEE 101.000-420^00(,'.
workers' compensation laws of California, and agree that if I should become SiTRO140 MOTION'".2,, R".';I-D t 0i-00;)-241,-0001 31.23
3 subject to the workers'compensation provisions of Section 3700 of the Labor G�t,rsC11TIF lt)jrt7d? .fix»{ 3itdl? !�R•>yn
Code, I shall forthwith comply with,those provisions. 0
at&'' - �a Applicant
Warning: Failure to secure Workers' Compensati n 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
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 MTP4 'T'E:Y,A" :�.�1k*n �;dFz—.vxg ixii):S mrl112v''a3wx, '1'%902°#•54
whose request and for whose benefit work is performed under or pursuant to LT`QQ �3 PRE-PAW k $0.00
any permit issued as a result of this applicaton agrees to, &shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees. sV' , " ,'�itT�'f #��.a9f� . O�y x�y
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 r
permit, or cessation of work for 180 days will subject permit to cancellation. -
i � J � � wv� IIIIIIIIIIIIIIIIIIIIIIIII
I certify that I have read this application and state that the above information is � 43
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 `� IE
the above-mentioned property for inspection purposes. ��— d
RECEIPT DATE" -I BY DATE FINALED INSPECTOR
,,-Signature (Owner/Agent), �-� T"•� "` •'"". Date �'• � ��� t: ' � �i f..� �— --�
. 1
INSPECTION RECORD
OPERATION DATE INSPECTOR OPERATION DATE TINSPECTOR
BUILDING APPROVALS MECHANICAL APPROVALS
Set Backs Underground Ducts
Forms&Footings -- Ducts
Slab Grade Return Air
Steel Combustion Air
Roof Deck Exhaust Fans
OX 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 — -S 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)