0305-0210 (BLDG) LICENSED CONTRACTOR provisions of TOR DECLARATION BUILDING PERMIT PERMITq '
I hereby affirm under penaltyof perjurythat I am licensed under 0.1 Z�L
Chapter 9 (commencing with Section 7000)of Division 3 of the Business and DATE ,e. VALUATION e a LOT TRACT
N W Professionals Code,and my License is in full force and effect. ?A,?r�L3
License# Lic.Class Ex Date
OJOB SITE
W i. �r:y� C a L�f~",C� P /91 Etd ADDRESS 81-2XIO
W i •`�
Z Date '`` �' Signature of Contractor t�r.£8,`i `a .v-: , OWNER i 16ONTRACTOR/DESIGNER/EN INFER
`r° o M4F. �;r`MES I�l�k;'-7V.V .1sDDIAU IyAMIR"MASO�+f:Riy W".
OWNER-BUILDER DECLARATION
J v � 81.,�r:�t i.t�1�'NC]�;62-- 3 ow-in.t:-1?i1��.r t'.:v;�,rt.il�J
WW I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) License Law for the following reason:
Z ( ) I, as owner of the property, or my employees with wages as their sole1j�43E'�1�'w�
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 GYNTi-"„f,�,j`
contractors to construct the project (Sec. 7044, Business & Professionals
Code). 50i"A". U' F1u1V'1&R7
() I.am exempt under Section B&P.C.for this reason OF PROPERTY,CIT F:�`e.A�i�!�1�2V..'t
O N� �Date - ��•2 4/"?? Signature of Owner
U 0)
Z WORKER'S COMPENSATION DECLARATION
�
Q cc I hereby affirm under penalty of perjury one of the following declarations: 61-7.AV IL.L 501 OP U?
�Z p ( ) 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
m _ Q performance of the work for which this permit is issued.
Q () ( ) I have and will maintain workers'compensation insurance,as required by
p U Q Section 3700 of the Labor Code, for the performance of the work for which this
Il LO I— permit is issued. My workers' compensation insurance carrier & policy no. are:
v ? Carrier ',.'�k� N. ji�39 3KE3;', 1�' Policy No. O�iC'E3.ar'J'L f Ct1t:'�'OF C OIC IVI'MUC:'T.[.�.44,
°�° O FI~:2RW. 1.1 I+�
Q (This section need not be completed if the permit valuation is for$100.00 or less). OfN:f•TA11GFTO?Z'F;L 1014!004 18-000 S144,01t
Q) 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 California, and agree that if I should become
3 subject to the workers'compensation provisions of Section 3700 of the Labor
Code,I shall forthwith comply with,those provisions. t
.,,,Date: �,r', !:,"i 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
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 f{,V ( PND PLM C M:�;1# '"r3 dr1.Uf�
whose request and for whose benefit work is performed under or pursuant to � U 1=3 PRE-PAM FFY�
any permit issued as a result of this applicaton agrees to, &shall, indemnify n LN
�
'
& hold harmless the City of La Quinta, its officers, agents and employees. V n. -
2.Any permit issued as a result of this application becomes null and void if • �r '�'�IM.NOW
16
work is not commenced within 180 days from date of issuance of such 1'tt�1
permit,or cessation of work for 180 days will subject permit to cancellation. ,.�fip, Ir _
I certify that I have read this application and state that the above information is Ct�tNA�� rat? , i IIIIIIIIIIIIIIIIIIIIIIIII 12
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.
RECEIPT DATE BY DATE N PECTOR
�.Signature (Owner/Agent) r ^%�� Date ✓.1.�/-1 -�
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 to Gas Piping
PLUMBING APPROVAY 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
i Final
COMMENTS:
Final
Utility Notice(Gas)
ELECTRICAL APPROVALS �� lir (� R6
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)