0011-277 (WALL) ICENSED CONTRACTOR DECLARATION PERMIT#
C/; I der penalty of perjury that I am licensed under provisions of f T BUILDING PERMIT
H Ch r encing with Section 7000) of Division 3 of the Business and DATE !{ r i. VALUATION LOT C➢ 2.1.- •7%TRACT
N W Prof "'siting s erode,and my License is in full force and effect.
O =) M License# Lic.Class Exp.Date
JOB SITE APN
ADDRESS �{
r— 40418 C79 r .�1 w ,�.��.NUR.5
r— r1_ OWNER CONTRACTOR/DESIGNER/ENGINEER
o Z r— Date Signature of Contractor
O
UOWNER-BUILDER DECLARATION JFFF.k .Y A COLE LEMMY DOIBM43 MQBON1{,Y
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor'sf14q' ,{j�[;t�IF;'�� $(^4" , k'3T4fV1'N C.�?1.'F.ft'
~ N License Law for the following reason: 1AQLWA CA 92253 PALM DEW I `g' CA 92260
Z ( ) I, as owner of the property, or my employees with wages as their sole
compensation,will do the work, and the structure is not intended or offered for (T5U)SgN�t3�'T � 2191
sale(Sec.7044, Business&Professionals Code). USE OF PERMIT _
( r)d 1,as owner of the property, am exclusively contracting with licensed IIIIIIII I III III I II IIII
,contractors to construct the project (Sec. 7044, Business & Professionals � �' � 49
Code), Zap,W.Ms< HR WALL-1550 L l".xI?AND IOU L.F.x de Pn3t IE
M O .I�am exempt under Section B P.,;'C.for this reason -
� �` I w \ ATTACHED PLA-14 �PP'�'t�'r�RD�1�°,1N,RR'Y IiERMAN,
N Date E �� i ("N Sigriature of Owner ._ T
Orn y ^
a z WORKER'S COMPENSATION DECLAR:At ON
p I hereby affirm under penalty of perjury one of the following declarations:
U") H O ( ) 1 have and will maintain a certificate of consent to self-insure for workers' 6 FT.WALL 150.00 LF
X W L= compensation, as provided for by Section 3700 of.the Labor Code, for the 6 FT.WALL 1100.01,A'
O J Q performance of the work for which this permit is issued.
m Q U -1 have and will maintain workers'compensation insurance,as required by
QU Section 3700 of the Labor Code, for the performance of the work for which this
L L Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Ob 5 Carrier LEGION INS, (140. Policy No. WC 11410864 15",rWN17D COST OF C ON s' UCTF014
J (This section need not be completed if the permit valuation is for$100.00 or less). GO�IF) �9'II(�}�J 101-000-418-000
(<)�I certify that in the performance of the work for which this permit is issued, sle ,ll�
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
subject to the workers'compenpatiion provisions of Se•tion 8700 of the Labor
Code, I shall forthwith comply Wit i those'p -vlsio•' "" i
Aate: ` Applicant
Warning: Failure to secure Workers�`Com.e sation coverage is unlawful and
shall subject an employer fo criminal penalties a d 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. r
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 y
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 SUB-'1 71'AL CON AM Pf. At (MCK CK 5180.00
any permit issued as a result of this applicaton agrees to, &shall, indemnify 1"l 0 PREPAdZ)1 $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 1191`.Lc 1^�`��Mf Fff.8:DUE NOW $381100
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation. O '�
1 certify that I have read this application and state that the above information isp(�'
• correct. I agree to comply with all City, and State laws relating to the building o ~'Y 1
construction, and hereby authorize representatives of this City to enter upon d►
the above-mentione�propert, or Insp ction purposes:
RECEIPT BY DATE FINALED INSPECTOR
Sfgnature (Ownedy.- . .� `� Date
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O"'ERATIO:-. -- DATE INSPECTOR +- - OPERATIOGq -� - DATE T INSPECTOR�
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UCa::2y Ne icu(Perm)
LICENSED CONTRACTOR DECLARATION PERMIT#
U„ I hereby affirm under penalty of perjury that I am licensed under provisions of BUILDING PERMIT
I— Chapter 9 (commencing with Section.7000) of Division 3 of the Business and DATE VALUATION LOTTRACT
cIJ W Professionals Code,and my License is in full force and effect.
O ch License# Lic.Class Exp.Date
JOB SITE APN
WADDRESS
0 Z r- Date Signature Of Contractor OWNER CONTRACTOR/DESIGNER/EN INEER
cm O'
J U OWNER-BUILDER DECLARATION +'raRl�+'�,f�at� ` � 5—aa�I `P�1L"� +„ k , A;il�$r
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's 80041 .��'.�:�UE 50 40.432IYET.MY��'C°3�s,�".�T
~ a License Law for the following reason:
Z_ ( ) I, as owner of the property, or my employees with wages as their sole ,
compensation,will do the work,and the structure is not intended or offered for ( �Cif56f3"5377 C.Bl i' 7,93
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 & Professionalsci ,13N�3
Code).
() I am exempt under Section , B&P.C.for this reason iI EIRIM9,"J 91Z WALL,w W.Wfrff a1'AN 100 L it x V PKK
O N �.
Date Signature of Owner f"�.diG'`�Ii�
RD LAW}�,1'1�'.1tt��N)BY JERRY��dta.liMAN,
rn
a Q WORKER'S COMPENSATION DECLARATION
O Z I hereby affirm under penalty of perjury one of the following declarations:
O ( ) 1 have and will maintain a certificate of consent to self-insure for workers' .b FIL WALL Do iff
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. 6 111111. I'.WA i0f7.00 i1p,
IM 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:
'IT Z Carrier Policy No.
cb O 1473GION 100.f"O. QVC 1 W10861 EFIWAA17 COST Or' t.;CY.1CiS:�E'�7�f'.TON ;f.�iX50,,M)
g (This section need not be completed if the permit valuation is for$100.00 or less). IIMZ. f IME 9UMIWA
RY
( ) I certify that in the performance of the work for which this permit is issued, CONS'►.'7�ICTION FF.;1? 101-000-418-000 SIX00
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
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 ander n�/
shall subject an employer to criminal penalties and civil fines up to$100,000, in t
addition to the cost of compensation,damages as provided for in Section 3706
of the Labor Code,interest and attorney's fees. I�
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 SUPWIViA,CONS[`ki.UCROK.A,ND RUM CIP $190,(10
any permit issued as a result of this applicaton agrees to, &shall, indemnify T `� a- � $
& hold harmless the City of La Quinta, its officers, agents and employees. ` iq�w??.e�1�?1K iia..0
S?
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
� aPW—Kt T �� 67 �
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 7� IIII II�I�IIII�IIIIIIIII E
• correct. I agree to comply with all City, and State laws relating to the building 50 !
construction, and hereby authorize representatives of this City to enter upon IE . A
the above-mentioned property for inspection purposes. — —
RECEIPT DATE BY DATE FINALED INSPECTOR
i
Signature (Owner/Agent) Date
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
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)
7