9912-012 (RPL)H
N W
W
Ouch
�a�
W
C:) Z
CD
IVCD
LIJLua
to
Z
M
LO
N
C Z
`in Cr
_m ��o
X W Y=
m.Q U
� Lo H
Z_
cb. 5
�.a
- J
NSED CONTRACTOR DECLARATION
I hereby aff` penalty of perjury that I am licensed under provisions of
Chapter 9 ( ng with Section 7000) of Division 3 of the Business and
Professional e, a d my License is in full force and effect.
License # Lic. Class Exp. Date
6561U C33
10/3117.04
Date � 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 the 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).
() 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-insurg 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
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:
Cartier Policy No.
S7'.r1Tf?' FCIT%X)
001- 99 1 N Fx.f;€^ 3
(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 whichthis 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 lshSuld become
subject to the workers' compensation provisions of Sectiorid3700 of the Labor
Code, I shall forthwith comply with those proyisions
Date: ' Applicant—
Warning:
pplicant Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for, in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building. and Safety
for a permit subject 'to the conditions and •restrictions set forth, on his
application.
1. Each person upon whose behalf this application is made. & each person.at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall,. indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void'if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. l.agree to comply with all City, and State laws' relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspect' o4purposes.
Signature (Owner/Agent,DateZ 6 a°
BUILDING PERMIT PERMIT#
iu3�2-11i
DATE VALUATION LOT TRACT
JOB SITE 79-490 C11,17RINO
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER /
tt�ltii l��n-.SaJi�i,Gv
�E�NyGII�NE�ER
�. I 1INI A TK,','01, 'AtS
` 1
.A3
ies-�f$A%}iL�,. ti�i? j u
i4-1":;.��1NI EJ i}.�l:, UA
LA QUINTA CA 92253
PALM D SfEXt'
CA
92260
f7'm.)MG-94x)[4
CnMt
i-55
USE OF PERMIT
•,lfcit��, e�t3vTJli.1�(. S�3�L
POOL .r'r;f3D SPik 0_W.Y-!?14. RM8,1BAkR.:fi3.iF:AS SHALL DE 4N PLM"T XT N.6
1700_L Al 17_,2A0.00 LS .
' ESKIIYA.C41TET'w..4d'ST6RFC9✓A .W. R,LiCTIOA@
�
0
_1712(9.00
r^;
f'.LAA: Ctd,I t"4i FEE10t,-f200-439-?i4
Mf+aS"i"R.9FC'! IO'NJ'4~'EE t01_i9*_4;R_4400 $1R9 iTn
rim 011
i 4j'l7ri
_
YIA'IJAY]dJAlV�JSF:.4:�u:•['V�JL - ..A.ii,e "�"✓�GC�.���'^Fli7M .A[yj. 1'.V'J
�"t
.`�
t
-
a
rr
l...i
,ESS PRX-PAID!, !,4;.RS
RECEIPT
DATE �` t
BY j
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR
BUILDING APPROVALS . MECHANICAL APPROVALS
L',t Backs Underground Ducts
8 Footings
Ducts
tabTns
Grade
Return Air
I
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
Underground Plbg. Test
Gas Piping
Exterior Lath
PLUMBING APPROVALS
Drywall - Int. Lath
Final
POOLS - SPAS
BLOCKWALL APPROVALS
steel
r 6rJ
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Final
Underground Plbg. Test
Gas Piping
_
�Z2 IPJ
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
Test
COMMENTS:
ELECTRICAL APPROVALS
Temp. Power Pole
Underqround Conduit
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temo. Use of Power
Final
Utility Notice
4