0001-253 (SATT)LICENSED CONTRACTOR DECLARATION PERMIT#
I hereby affirm under penalty of perjury that I am licensed under provisions of / BUILDING PERMIT 00401-ZS:i
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and DATE VALUATION Vilti4.96J.St4 LOT IS TRACT w71r15
N W Professionals Code, and my License is in full force and effect. , �-
License # Lic. Class Exp. Date _
r-- CJ In 6-7 411711 L: 076 i, 201 JOB SITEADDRESS 49-250 CASA) AR ��GZd.'�� APN
LU
I,- Z �� OWNER CONTRACTOR / DESIGNER / ENGINEER
C Z r` Date Signature of ContractC-4
(D O f` 0-1 � ttiv� r; r+-:��-,r,�n';c nruti�rnrr cU.r>F-el r�rjprre rrt r/ r rr�r.t
I., t_. 1.. ki1.,f\ 0 1 :1. l l-letiJ! ... 11.., 1 1 • \MLI I ..• a::.11 1.\,,,f 11.11 "•
r`_ 1= � OWNER -BUILDER DECLARATION I ry, h ,
J U r— 1'L.! jsi Ci i 7 i �, 79-P3 !, fCAN€ R6 LA +"3UT,r fA DR,
H Wa I hereby affirm under penalty of perjury that I am exempt from the Contractor's t A QUI C'.rV �?�, ; l.:1 111►.(I� 1'a CA �► ►1
+`3 i; 1 7
U) License Law for the following reason: `
Z_ ( ) I, as owner of the property, or my employees with wages as their sole r?F�f1►?7f-I�F4f (."..131.1! ,'9+�(i
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 iiNirL6;) ANIHN LiWELL,iX,l
contractors to construct the project (Sec. 7044, Business & Professionals
Code). / So i-) LQ1 ia) j1_) (v r>,-e6--41IT FAA:., '9GT s-i�ii_LUJJ-JE BLi X WALLS OR
O I am exempt under Section B&P:G. for this reason l,riia, 'l4yi,,j�l�:1N (A-JE1_'k.!•` ti 3LrCrC`i'it.%Ed t ;)K, 141U1.'1'31'l.r; itiSUtLPIi"6i U.1
N Date Signature of Owner .1/�i21 Pf.At+t TYPEN
CL Z WORKER'S COMPENSATION DECLARATION
C) Q Z I hereby affirm under penalty of perjury one of the following declarations: ;;; E; „4i c,,( ;ti :?'t2i;t"i'i✓iv 1..i7,S.vC Si
T I -Z O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W L= compensation, as provided for by Section 3700 of the Labor Code, for the in_,A+A"1;P X I -It l50,t10 si
O J Q pert rmance of the,work for which this permit is issued. k-iA tAOtYk;Af� -hi C 46.5.00 4i
M Q C) ( I have and will maintain workers' compensation insuranoe,,as required by
p to Q Section 3700 of the Labor Code, •for the performance of the work for which this
li rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
qt z 00 z Carrier Policy l;,df_I Policy No. 4.1f 1irtr!, 3`; 'i "�°'�°'i`� g!.i) M i Zi'7 r aT 1 m�:
g (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; t f rN`'tfttir.°t'1t.�N ht:1: IUi-Ui)1.� �1 ri11t1�i7.(ni
I shall not employ any person in any manner so as to become subject to the Pi AN ( 'F{Frr, 144". 1(11-000-41+)-11 +t $ )?ri. rll
workers' compensation laws of California, and al, a that If I should become f1t L'ti1L�31r.'.;1. 1'1 101 (W -421I. -NO $i€r 1.00
subject to a ��,yk+kers' compensation provisions Section 3700 of the Labor j�C.Liti:'i'lth�r�l:, t !als 101-t?0O-1."1�-UEiii �+t.t: y {
jLsjl.foftdhwith comply withthose visions
ate: 77777 7/J/�7 .�
Applicant -4=s / i'f,.UNt1$1Nc: FRE, 101-00041940) S
TrI?("tNT(1 f1,tC:'1IONY' -RF,$IT1 101-('t1f1_ )d1-Ot'r1 $!6 10
Warning: Failure to secure Workers' Compensation coverage is unlawful and ; ',�;.df:9 ;'?ts rrr
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 DEA1 i-oPL IR ItWPA�T 1, L -.ft $1, 5(.%0,t1
of the Labor Code, interest and attorney's fees. ART 1N P(JIFI Ic Pl.r1.CES - RE AU 701-000-255- 0 3!62Ao
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. c.
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 ;t r ,t q (, <'f1(�f 1 and A 1x11 Pf A iV r 11t,r 1€- 101119
any permit Issued as a result of this appllcaton agrees to; & shall, Indemnify
& hold harmless the City of La Quints, Its officers, agents and employees.
2. Any permit Issued.as a result of this application becomes null and Vold If
work Is not commenced within 180 days from date of Issuance of such I•u,TAL P1R'RN181 " FEES :9. 0P, Nl'ttjri/
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 authojlz representatives of this City to enter upon
�th,llaibove-mentloned,prope,V-forIns Qctio rposes,RECEIPTDATE B DATE FINALED INSPECTOR
iignature (Owner/Agent) ` Dat 70th
INSECMN RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
. BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
r
Underground Ducts
Forms & Footings
Ducts
Slab GradeReturnAir
�_
Steel
��
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
Framing
F.A.U.
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 . Gcs
BLOCKWALL APPROVALS
Steel
POOLS a SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
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
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 _ jOlt
Utility Notice (Perm)
COMMENTS: