0204-204 (COMM) LICENSED CONTRACTOR DECLARATION PERMIT# }
I hereby affirm under penalty of perjury that I am licensed under provisions of BUILDING PERMIT
HChapter 9 (commencing with Section 7000)of Division 3 of the Business and DATE VALUATION LOT TRACT
04w Professionals Code,and my License is in full force and effect. •'' ,NKf.FJ9J
-
O :) M License# Lic.Class Exp.Date
JOB SITE .�• APN
483630 1? t' t ADDRESS $!:Zd1ifl7�d: 43
IZ
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Z � ;i /,alar.p•! A. 4 — OWNER CONTRACTOR/DESIGNER/'EN (NEER
Z r,- Date Sgnature of Contractor
r ~ o OWNER-BUILDER DECLARATION `� TONYA LITAU LA, 1NIAND'i�d�.x.1'�°CyC3 if3TItCl�"€IC9 f `
Uo . .
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor'sl-t�bUETE��,.`d11i(J 1, SL7' i t��r" ;
' aa..&QUIN' A two 9«:25 3 BL-001AWG.['C:a1 T CA 92'316 rd V•
r) License Law for the following reason:
Z_ ( ) I, as owner of the property, or my employees with wages as their sole � 0955'i S�2I1 d v ?I;f11 u5Q7`
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 C°C>Ml+r`LG �,L
contractors to construct the project (Sec. 7044, Business & Professionals
Code). U`l`4.M ,h NFD d:ELI X.1.,AF.'I'XF1XPHOWko SITE ON tXISTII+G Z'f7'°W1k;130
t () I am exempt under Section B&P.C. for this reason LF,V CHAIN 1.M k,'_iC 1s(U,2,000LIP•A:NC'Y).
N Date Signature of Owner
O CV
Li Q WORKER'S COMPENSATION DECLARATION
o z 1 hereby affirm under penalty of perjury one of the following declarations:
r < 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
OQ performance of the work for which this permit is issued.
C0 Q U .O 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
Il H permit is issued. My workers' compensation insurance carrier & policy no. are:
Z Carrier a'fAT;j f�'U14D Policy No. 044-DI UNIT 01:49:333 MIAWMD G•`09f OF CONYMUMION .00
C) PEPMUT FIX SUMMARY
J (This section need not be completed if the permit valuation is for$100.00 or less). Pt,{.N CKIECK PPE . '101-000.439.318 WIN
( ) I certify that in the performance of the work for which this permit is issued, ;014S`RUCTION'"We V54.50
I shall not employ any person in any manner so as to become subject to the 'I IQ1-000421.000 $1.6.00
workers' compensation laws of California, and agree that if I should become
subject to the workers'compensation provisions of Section 3700 of the Labor,' a.LL��?1G.F'�7.•1'irlr 11"f300-4212"t141� �s,I.si9
Code,I shall forthwith comply with those,provisions.,
Date:l• = 'e: �'-Applicant
Warning: Failure to secure Workers'Compensation coverage is unlawful and 1 f
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 CITYOFLAQUINTsk
for a permit subject to the conditions and restrictions set forth on his FINANCEDEPT
application.
1.Each person upon whose behalf this application is made&each person at SUB-'1 OTAT 0014=1IC3IMAWD PLAK(ST9 .
whose request and for whose benefit work is performed under or pursuant to 1 , P 1 '�S0.00any permit issued as a result of this applicaton agrees to, &shall, indemnify �9
& 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 TMAL FE1 M.r PIKEfi D11141,now
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. IIIIIIIIIIIIIIIIIIIIIIIII
1 certify that I have read this application and state that the above information is 44
• correct. I agree to comply with all City, and State laws relating to the building IE
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purpses. f, RECEIPT DATE BY D FIN IN ECT
r f:
Signature (Owner/Agent) / t� Date ' O
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
BLOCKWALL APPROVALS steel POOLS - SPAS
Set Backs Electric Bond
Footings Main Drain
Bond Beam Approval to Cover
Equipment Location
Underground Electric
Underground Plbg.Test
Final I I 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 �/
OLS
Final
Utility Notice(Perm)