0001-244 (SATT)H
N (n
W
o:)co
CYW
r` P_
C Z
CID
H(0
IW— d
CO
Z
cr)
L0
N
0CJ
UQ
Il Z
`rH0
0 J J
M _J
O: 0)
Z
r- O
R
LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 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
o'7aii}7.1 Cs � 713Ii�il+
ate Signature of Contractor r
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 the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
( ) 1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
( ) I am exempt under Section 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.
.( )% I have and will maintain workers' compensation insurance, as required by
S on 3700 of the Labor Code, for the performance of the work for which this
permit is issued. My workers' compensation insurance carver & policy no. are:
Carry Policy No.
r. Y 41;• li •_. 1.11.+ "'I, •L,L).11 J.,+IC
(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 orkers' compensation provisio s of Seoon 3700 of the Labor
? els s II f rthwith comply with those prov' ions,
Bate: ? Applicant
Warning: Failure to secure Workers' Compensation coverage is unla ul 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 mode 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 request 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 harmless the City.of La. Ouinta, 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 author a representatives of this City to enter upon
t e above-mentioned propertyfo ir�sPection oses.
r
Signature (Owner/Agentr f' Date2/7 2 f_�
BUILDING PERMIT PERMITp
DATErJ.. VALUATION $11(t�3(iU ¢,91 LOT J1 TRACT - i?IiZS
JOB SITE
ADDRESS -'��1� L r l� 11��.i � �Y4i APN 649-.380-006
OWNER
CONTRACTOR / DESIGNER / ENGINEER
IP-o-r •r-' i r�...l �\ A l._. 1., M 1,.1•Vl 4+l -•41 1 dl 1 a,t••./IIJ ✓l.0 a "v • , , -
PO
PO BOX 1 716 79-295 idmNCHO LA Q)Li11JTtA, DR,
LA QU()` TA CA 92 4 LA Q1 AN'rA Call 9*2153
f76M771-1944 CM.4 2f196
OF PERMIT
`tijPii'i J, 2='ANFIL1' iAVt':I,l..tN(;
Sri:! LCc 71 Pf.riiN N t'EWviiT UO S NO iNCLURXE BLOC>;: W:>:LLS OR
i'C}C1i,,.75°�o PLAIN 0111'42-K iota RhOL1t"'1' ON l-C>k.Ail ULT 1PLI? I SSI}AN(:E lily
q r
:,1,iV( �.vi•s`,;bi'icliL-TI�iiJ i„ '•r.j �w Or
P ORC1l:f/t'. C i X) i �V' .00 :if'
"'N'Togqr�R'1�trt�ne", r+��rs.�n�rrrwrr>nl
A.—OF /.AhY., .d.0!, R-+ .V4Y� 'lIS'
Oyl114iV1.d 8�'6?:k �dJCV1lfVdr��6�t
C0N:3'1'tUX,11(_)N FEE
I0.1 -W.) -4184M)
93ry'l.Im
P1: AN 414F. I 1 )'.
t f )1-<t(}ft,.:t'in- i) i �
41 14 74
la TIC NA, 1.ft /,i. 1_.
l+l. 1L 1- 1
I 1 i>i l �e"i4"AL ("a"
Wh-060-4v-wo
!'a ION4"U h' N'
I G 1-f 00-419-M)
R.if'aION t Rrr _ IJO'�110
141114)00 -`,+ill -N)0
$1Fi,i41
I o;ZAI;t1JIG )"ltU
101 -OW .f2:;.000
$'N) 60
i rEt''F L1.A''1_U ITSit'':tt:"1' i } is
Vii, i1.Ul)
A&T JN Kliit_iC' 1"t A4 t t - it1 `f LG'
'tlil tiUfi-l��-(It1i1
3lf�l/tir
Sf r13 _ Y)TA 1• C(M,-14 ..It`'TI(_)rd ANl-) T11,A1 N CJ fr,{c'.I;
I.'E'S.o" "RE Int'\I.1) F7. E.3
RECEIPT I DATE
'S'01"AD., vil."' tIMIAT Vw,.F's 014"'N 111+ 1 � 9,Z.6if.t3P
FINALED IINSPECTOR
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
_ Cif
Underground Ducts
Forms & Footings
Ducts
Slab GradeT-7—Q
Return Air
Steel
Combustion Air
Roof Deck
C(%
Exhaust Farts
0. K. to Wrap
F.A.U.
Framing
Compressor
Insulation
G
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wali Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
- 44, )
Drywall - Int. Lath
: f
Final
Final
13LOCf"rZlf ALL APPPROVALS
POOLS a SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground P1bg. 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 <iAn
Utility Notice (Perm) - 64 41 W
COMMENTS: