9808-143 (SATT)LICENSED CONTRACTOR DECLARATION BUILDING PERMIT PERMIT# CONTROL#
I hereby affirm under penalty of perjury that I am licensed under provisions of
H
Chapter 9 (commencing with Section 7000 of Division 3 of the Business and %mix- � 3
P ( g ) DATE VALUATION LOT TRACT
N Cl) Professionals Code, and my License is in full force and effect.! Gi a�(►,yLIl.;i41 ' ''
:3 M License ,# Lic. Class Exp. Date
C) JOB SITE APN
ti �i 41)''� ki J' �liilJ` -� ADDRESS 48-235 d..ASiTA bRiVE 6494.�+i�4-li�i�
CZ /ate f �" Signature of Contractor l OWNER CONTRACTOR / DESIGNER / ENGINEER
O,
r-- U C) OWNER -BUILDER DECLARATION
H LU I hereby affirm under penalty of perjury that I am exempt from the Contractor's P.10. 1: OX. 1716 '79-295 RANO-10 LA QU1NTA DR.
CO) License Law for the following reason: LA (AJ AJ+1'1 A CA 42.2 3 LA QU1Nifti C A 97-253Z ( ) 1, 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 (7i�ii t77) - M11 C 13T�r. t�
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 & Professionals l F; FAMILY XfTA(A!F*D
Code).
c () I am exempt under Section , B&P.C. for this reason SFAPLAN A, LOT A 51. PETUVil' DOES NOT Ui LUDE. BLOCK WALE
LID
N Date Signature of Owner0 CM k)R KARL. PLAN Offi-'K. Fr B R3,DUCED 7Y",0 FOR MUl.,11PL1, 1°,r'tii,IP,.NCe, OF
a_ Q WORKER'S COMPENSATION DECLARATION
SAME P1. AN TYPE,
p cc I hereby affirm under penalty of perjury one of the following declarations:
Lo H 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 CU i 1 ON1 C'.. 'A4.S1'RUCr10N 1,975.011 sr"
O J Q performance of the work for which this permit is issued. P�7Tt0 /1"KHO 150.00 SIF
M Q < ( ) I have and will maintain workers' compensation insurance, as required. by t.Ak�lCil It `,31t't'(i`3C.9 as ti,(rU SF
Q U Q Section 3700 of the. Labor Code, for the performance of the work for which this
2 L Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
r- O S`f a'? FUND 1-1 It I(1;13ft;t:"e'S.'2!�t
g (This section need not be completed if the permit valuation is for $100.00 or less). K MIT FOESiijtlTNAA Y
( ) I certify that in the performance of the work for which this permit.is issued, i3ON8'IWX,'19i() f'T-. ' i(aI.�000-118-1150) �K�ti7,ta1
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree If I should become Pt., A1�(t: HFr'�: rP3 . 10 l .fl{j(1. � a,317 S�17g, A
subject to the �yOrkers' compensation provisions -of S ction 700 of the Labor IME't.1�0141C AL CLC 1f11-4�'J- f21 (}iltJ $1(if,10!
Cdde, I s�iall oath ith comply uGith those grdvisions. j ULZ "1'1�ICe�1, FEE ItDI-4t1Q-d'2(H1t10 $135,93
Fate: 4n 1 f• Applicant: •'� , ti� ,�
i t 1PLLf1vdd3I_NQ F 1*1' I l} i -(1�t) �11,t i3(fU $15 -.
Warning: Failure to secure Workers' Compensation coverage is unlawful and STRONIfF',4riDT).<)N FF5: - I?F-31f' 101-(lf3O-241-(l) $16.so
shall subject an employer to criminal penalties and civil fines up to $100,000, in (JRrV_).'Klr ( }vi ilr l-;�y3-Q11� its
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees. f,N) 41,A`i 1: i2,llt_"1 (JRA? F13F, 2 2 5- U& 4-11. S•3,466.7,;
IMPORTANT Application is herebymade to the Director of Buildingand Safe ALC i tad VtJ i1.1C; 13i.Ai:'`3 • i2E51L
for a permit subject to the conditions and restrictions set forth on his '14
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 k
any permit issued as a result of this applicaton agrees to, & shall, indemnify it -roa A!�,,�I; 71'(,t�?J d"_`.. 5, )4t,�'i
& 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 ifAUS G 2 � �� 1 3 LESS P11�:-PA.(D : E[('S $0..(t0
��
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. �PTAL T}'P`Fi1 Iff FFF.S 01:,151',)iOMr ��i,gQla� yT
I certify that I have read this application and state that the above information is OF LCL Q,U` r
• 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 inspection purpos i I
RECEIPT DATE Bl^ DATE FINALED INSPECTOR
Signature (Owner/Agent) Date
NSP CTM RIECOR10
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Q g-
Underground Ducts
Forms & FootingsDucts
-�
Slab Grade
-
Return Air
Steel
Combustion Air
Roof Deck
W
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 —
BLOCK ALL APPROVALS
POO[LS e SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
CPL9.DRiISHIS APPROVALS
Gas Test
Electric Final
Waste.Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
'Equipment Enclosure.
Shower Pans
O.K. for Finish Piaster
Sewer Lateral
Pool Cover
Sewer Connection
VEncapsulation
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
i
Final
Utility Notice (Perm)
COMMENTS: