0006-273 (BLCK) LICENSED CONTRACTOR DECLARATIONPERMIT#
I hereby affirm under penalty of perjury that I am licensed under provisions of ";-061 BUILDING PERMIT
HChapter 9 (commencing with Section 7000) of Division 3 of the Business and DATE VALUATION LOT i* %� TRACT
N LU Professionals Code,and my License is in full force and effect. %2,$1130.00
O ch License# Lic.Class Exp.Date
LLJ f lcr �c JOB SITE
APN
ADDRESS
S0I)1AVAT 48
Z I-- ',Date 44 Si natureof Co � OWNER CONTRACTOR DESIGNER ENGINEERINEER
cop
J U� OWNER-BUILDER DECLARATION T.D.DESERT.�EWLOP NT' -ARV1,CO:r STRUC.:T 01i
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's P.C),;BSQX 17 16 799295 RM MO LA QjNTA DR,
~ U License Law for the following reason: r LA QLTMTA CoA 92253 LP CMZ:WT2l. ?� CA 92253
Z_ ( ) I, as owner of the property, or my employees with wages as their sole ( 60 7'7 j 941 CIBI�ff 2996
compensation, will do the work,and the structure is not intended or offered for
sale(Sec.7044, Business&Professionals Code). USE OF PERMIT
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals (' 13$, §il4LI�I1C�i
co Code). BI OCIr.`i>U'AIX.2300 Lia. @'HIGH PFRJMZTCI2.h9'.r',.gUPIt�i1vY Vve�1L
() I am exempt under Section B&P.C. for this reason
N Date Signature of Owner FROM DE E PALMS ROAD TO JEFFER ON.C�.F�CO STANDARD
O rn TRACT#29457.1
Q WORKER'S COMPENSATION DECLARATION
C2
cr I hereby affirm under penalty of perjury one of the following declarations:
r < O ( ) I have and will maintain a certificate of consent to self-insure for workers' 6 FT, WALE. 2.540.00 LF
X W compensation, as provided for by Section 3700 of the Labor Code, for the
O _ Q performance of the work for which this permit is issued.
m Q C) ( ) I have and will maintain workers'compensation insurance, as required by r
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
Il rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
It Z Carrier STATE.I711ND Policy No. 046-0007332 ESTD61ATED 06391 OF CONSK UC'I'I0H 652,5W.00
Q (This section need not be completed if the permit valuation is for$100.00 or less). CON3TRt�CTIO�J ITEC 101-000-418-000 �9°T3.00
e _J ( ) I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of Cali ornia, nd agree that_i I should become
subject to she workers'compensation provisions of Section 3700 of the Labor
bCode, I shall forthwith comply�wlth those provisions!
iDate:l �a Applic( ipeant ��r� j
Warning: Failure to secure`Workers-E;6 nsation coverage'is unla ul 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. f�
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
'� �C.c�N'CL�C:� S71•T T'I `I CIRIXX S473.00
any permit issued as a result of this applicaton agrees to, &shall, indemnify .c..c;w 9 P. P.i.•I.DFEW $0.00
& hold harmless the City of La Quinta, its officers, agents and employees.
2.Any permit issued as a result of this application becomes null and void if TOrrAL F15M:E MIS V117F.1g0W $47.3.00
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.
I certify that I have read this application and state that the above information ii IIIIIIIIII�IIIIIIIIIII�II 47
• correct. I agree to comply withh all Cit and ate laws relatingto the building
const(uction, and hereby authoriz epresentatives of this City to enter upon IE
th above-mentioned property for inspection pu�oses. RECEIPT DATE B /' DATE FINALED INSPECTOR
Si nature (Owner/A ent) i / Dag"f/ -�'•�r'? 7 s-"=
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
Bond Beam Approval to Cover
Equipment Location
Underground Electric
Underground Plbg.Test
FinalGas Piping
PLUMBING APPROVAL 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)