RER (0002-171)LICENSED CONTRACTOR DECLARATION,
,I hereby affirm under penalty of perjury that I am licensed under.provisions of
a60ter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and -my License is in full force and effect.
License # Lic. Class Exp., Date
10/31120i
ateT �� -Signature-of_ Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following'reason:
( ) I, as owner of the property, or my employees with wages as their sole
compensation, will .do the work, and tiie_structure is not intended or•offered-for
sale (Sec. 7044, Business & Professionals'Code).
( ) I; -as owner of the :.property, am exclusively contracting with licensed
contractors to 'construct the 'project (Sec. 7044; Business & Professionals
Code).
O I am exempt under Section " Y B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury 'one:.of.the following, declarations:
() I have and will maintain a certificate of consent to self -insure for workers'
compensation, as provided .for.'by Section 3700. of .the Labor Code, for the
performance of the work for which -this permit -is issued.
\,(JAI%have and will' maintain workers' compensation insurance, as required by
Section 3700 of the Labor Code, for the performance of'the work for which this
(permit is , issued: My workers' compensation insurance carrier & policy no. are:
%Carrier Policy No.
010 ,),^•w'r,' , 1^ rS. at r� Q:.a AIYea, t ,
(This section need not be completed if the permit valuation is for $100.00 or less).
() 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
subject to the workers' compensation provisions of'Section 3700'of the Labor
Code I shall fohhwith comply witkrthos prov signs..'
A'a Applicant a
r /
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
whose ,re,quest and for.whose benefit work,is performed under or pursuant to
any permit issued as a result. of this applicaton agrees to, & shall,, indemnify
& hold 1. 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
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
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
the above-mentioned property for ins-pec�tion'purposes.
Signature (Owner/Agent).- ?� �--�� �' Dates/ I
G, N - , --
PERMIT #
BUILDING PERMIT
DATE VALUATION
.52",300 , 00 LOT TRACT .• 32 /73-2JOB '
ADDRESS 78-656!A'�IL�.�L.I�IANI EVAN
APN
OWNER _ , •_ - _ _ CONTRACTOR / DESIGNER / ENGINEER
r-+i;"AST11 Z't'� V��•�.• 1? /16'iT,1; t i' f"''('�AJ1A dY S'Ai'F `1-Z. Y r"�'!t0tV. P r r,f-%NA'h,4r fhYM117e.'
t.i a: 4�. 1 V.R l �.. ••Li.J ,11:A.A, V,wY.J�J. 41,)Wa!1 d.' tf:r�, 'tia-rti SP,4.1, \.a YJ Y s:.l�,..•L.1d( .11ilV tM A.A Af•.Y.,
153.5 $p. -D" SMM, ,S"1E. 4200 1535 SO. "D" ET-IREEr, iM. •ir?W
SAN BERNARDINO CA 92409 SAi� AERNA1t.DIN1Ct CA, W2408
. _ai ) 8#•ti00� CB1.4 21201
. r
USE OF PERMIT PAID
r
RES 17D - C t�',i...iRE . 40 D. 1.
{7Ai�,at E �utdi(fr<;iESiUYti TO SALBS vi ii'i % 14 Z MOP 49!NI1IT,
.� a
OF L
QUINT,
ill
•
is
Z-500.00 LS
°'i 1sti�i rAc a a a}+s i la�t t v n ar,C L siiiA3i
� w i.iieAr '
:aEl3' PEE, SUMMA :V 1
PLAN CHECKFEE'' 101-000-439-318 S35.10
-'s',.9-0000 $544.((!y0
CY�1TJ`r'i`13tJ�tv,rFIGN f�F, ioll-.(}fJi
/O
.11`�'E.,01A.NIMAza
l',IY.!1.t'lel.rC0N81,,RX_TC`li�0NT r:'4.NP S -1,A CHI•1.'4\-.1e,
$104.60
.ESS PRa'4)A1V 1718ES
$0.00
ME NOW'
RECEIPT
DATE
BY
DATE FINALEDINSPECTOR
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
POOLS - SPAS
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
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)
COMMENTS: