0204-208 (RPL)LICENSED CONTRACTOR DECLARATION
1„ hereby affirm under penalty of perjury that I am licensed under provisiogPlU ,
6hapter 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
6146'11 0,53 S.,
Date Signature of Contracto��
OWNER -BUILDER DECLARATION
Ihereby 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 -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.
•(d. ), 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:
Carrier :A.Policy No. tl60E
(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
�,s�ubject to the workers' compensation provisions of Section 3700 of the Labor `
"ode I sh II forthwith comply with4hose provisions. ,/� ,,.^ `t
Date:T' V (0' 02 Applicant --
Warning: Failure to secure Workers' Compensation ato coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building aria Safety
for a permit subject to the conditions and restrictions set forth on his
application. ,
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify a
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby- authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
f Signature (Owner/Agent) . Date'~ C)`A
BUILQING PERMIT PERMIT#
DATE �PVALUATION
}4SJF, LOT ,;y ,4 ,sir TRACT
JOB SITE1��-1965
ADDRESS 7!^U1. 9,MMI" WUST
APN
^
OWNER
CONTRACTOR/DESIGNER/ENGINEER
199-3110N .�+'gi�iMES
hA(�p'Di�n�°1'c1�:� V.�FOOLS &S�oh,.S.�.
'"yY Y �y {ryM��y
CL
f 1 - 64 AMY7✓dV�l�.l�� CLr�;R'8d8N.9 FE 44 JY
1P.01..iln. X 1791
PALM, DESERT A 922211
CA S.:>UWTA Ch �rA253
(760)NOX.4535 C.131. 1945
USE OF PERMIT
YOOL.MfUR STS
T L,ANT) S@?J::wJ3�7r .'�:" A.LA.`Rtl0;4,r§AP'_R* .,SHALT.: BE IN MACX V10011
VOM ANT:3;fOR SPAt
",Www, g S$w "Y
101-000,43.9-318
K, Ye�y tQ��
'yea`.q�.w.,��7��t�al'a�
�)
V»Od,a JtTJ(, �8�..�bV :�Ild'+�3 101400-4 8 -OW �V�RISM.W1�
+
ayye�rL��ppip/k}yy,��O.�i,MCgqil�:gqr —yy33Tyy"8��3yy���3HR b�gqS1.L��3(s93
jjp�)�i�pli-/F���il���pp$.ap�y?giy��
•a.SS..6F.l,i.S,i6MF,P AT, J -M, ^'^'.:5-'�-X% JiV:F °�e64J' St� . �'7'r ,00
LJ y
"2ul t�U2
I:p 4a'a F4 nVSX.'vw p.2,m t.u)Ab�.vLa.
'N.JR9..i�4�
,A
�1^�/!C�,RFero
174` LESS Pk VATI3.E4;28
$0.00
y.
RECEIPT DATE/ BY DATE FI ALED INSPE
F�y
R
[I k, M- •UK, KT:•-�
' OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
1 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
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
— d
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
yGas
Encapsulation
- =p
Piping
Gas Test
Appliances
Final
— Z
COMMENTS:
Final -
Utility Notice (Gas)
t
ELECTRICAL APPROVALS
Temp. Power Pole
U'Merground Conduit
Rough Wiring
r
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
y
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
F
•
CITY OF LA QUINTA
BUILDING & SAFETY DEPT.
APPROVED
FOR CONSTRUCTION
uA,11