0111-115 (TEMP BLDG) (AVE50/JEFFERSON) LICENSED CONTRACTOR DECLARATION PERMIT#
I hereby affirm under penalty of perjury that I am licensed under provisions of BUILDING PERMIT
Fes– Chapter 9 (commencing with Section 7000) of Division 3 of the Business and DATE VALUATION LOT + TRACT
c1I W Professionals Code,and my License is in full force and effect.
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License# Lic.Class Exp.Date
-� JOB SITE APN
O �} a4� l�UC:.A K 7 C�� '� ADDRESS rI I�Al ' ��x i eS(-
Z ►�• Date `� Signature of Contractorr� OWNER CONTRACTOR/DESIGNER/EN INEER
d O �-
JU (D OWNER-BUILDER,,DECLARATIONB t''11E ASIS1A,T1; _– `� i 3 ;1N`4�.f�.�,�rWkq ,Ifif;.
W W r- I hereby affirm under penalty of perjury that I am exempt from the Contractor's X)IXYX 8l(D 1425 Z TNIMU.-TI f DRM
~ N License Law for the following reason: Lk QT;,wA CA 922.53 S�'iz;OM `' AZ'f 8503
Z_ ( ) I, as owner of the property, or my employees with wages as their sole (602)22 57.656 CISLO
compensation,will do the work,and the structure is not intended or offered for
sale(Sec.7044,Business&Professionals Code). USE OF PERMIT
r^"I, as owner of the property4am exclusively contracting with licensed
/contractors to construct the project (Sec. 7044, Business & Professionals (P--NEIAL
M Code). TEMPO%'W�6.R Y:i'k'9171,:l8'X 15'3):{�STRY`�'R.i;N„4.. S C.A'NOPY`(3 32 a.r.)a
() I am exempt under Section , B&P.C.for this reason
O N Date Signature of Owner �'ED '`SRIAH kBH;•(t'L"R FOR.MODEL 1;'0MVIL '
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9 z WORKER'S COMPENSATION DECLARATION
C:) :E Q--
I hereby affirm under penalty of perjury one of the following declarations:
Lo H O } 1 have and will maintain a certificate of consent to self-insure for workers' L'C�.i.fr9ki3'A.'i' U S ,f)tt �
X W �= compensation, as provided for by Section 3700 of the Labor Code, for the 'VAI DATION ;7,924,00 Ix
O � Q performance of the work for which this permit is issued.
m Q U ( ) 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 rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
aob j Carrier INS,Ck�Al.{l�'.�,,k'�''Y OFT Policy No. ' ,, IW080 'E vim'. E)Cost OF COINITMUM170N 2A.9"ku
g (This section need not be completed if the permit valuation is for$100.00 or less). PLAN G3ir�RZE _ 101.000-439.54S S03,60
( ), 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 C;UNSTl2.Zd4v'iIUR;'7,17, 1 1"�a{I4►"' •£�`(7FJ�� �a3'�.Or1
workers' compensation laws of California, and agree that A I should become ST:R-O. O MOTION RT`-I'MSID I M-0oo-242 s-000.' S150
subject to the workers' compensation provisior)s%of;S,edfron3700 of the Labor
Code, I hall fo ith comply with those pnO isi6A
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 DEC� U
for a permit subject to the conditions and restrictions set forth on his Ml
application.
1. Each person upon whose behalf this application is made&each person at cam®
whose request and for whose benefit work is performed under or pursuant to �).k?k?-'� �4� 10 AN 01MCR 18.30
any permit issued as a result of this applicaton agrees to, &shall, indemnify 'S FRX-PAM ERD $010?
& 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 :l°W:AL[/TETE tT)MS Z AYR# NOW V&30
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 is IIIIIIIIII�IIIIIIIIIIIIII 30
• 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 ,.,h IE
the above-mentioned property for inspection purpoSeg' "
„r � ✓ ft RECEIPT DATE BY D
�TR
Signature (Owner/Agent) Date r
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 C — 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) /�