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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.
�-`I* License # Lic. Clas Expp.Date
s
C-52( .5 oil
,/da�te .1ignature of Contractor
OWNER -BUILDER DECLARATION -
I hereby affirm under penalty of perjury that Fam exempt from the'Contractors
License Law fo�r f1he following reason:.
( ) 1, as owner of the property, or my employees with wages as their sole
compensation, will do the wor�',_and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
1, as owner of the property, am exclusiv�e[y,,pntracting with licensed
contractors to construct the pro,ject (Sec. 7044, Business & Professionals
CodeY
I am exempt under Section B&P.,Zor this reason
Date Signature of Ownert
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 Lab6r Code, for t6 . e
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 perfoiTnance of the work for which this
permit is issued. My workers' compensation insurance �arrier &'policy no. are:
Carrier 'Policy.No.,
CLAR0,00,44"W4 1"t. 04 P%, Rv= In 1
(This section need not be completed if the permit valuation is for $100.00 or lessi.
( ) Ice * rtify 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
'alifornia�
workers' compensation laws of C and agree that if/17sho'Uld b6come
subject to t e workers' compensatiop prdvisiors of Section 37 .00 d/f the6bor
C50e, I spall Avi hcomply with tl,!�.szovisions.
,Date: V4' Applicant.- 1A
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employerto 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 purs ' pant 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 . becom es 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
N " W "0 -
correct lragree to comply with �(City, A�d State laws re,lating,to the -building
construction, and hereby authorize representatives of this City to enter u on
I f I di I - If'
the af6ove- mentioned property fovinspe io� purpo es..
7
t,Signature (Owner/Agent ate
BUILDING PERMIT' PERMI T #
DATE 09mm" VALUATION S1!5,jM,(
y) LOT TRACT
'0' SITE
ADDRESS '73,865DAYBERRY LANE
APN
.OWNER
CONTRACTOR DESIGNER ENGINEER
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T), f 1 TQ ff A I � 17 N I P,()J1 V
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'78 865 B AY B E IM Y LN
23 18 S. VINEYAR0 MMUILT, SUITE A
LAQUINTA CA 92253
ONTARK) (�A 9.J r7,) I
P909)9471 -A414 CIAO 5246
USE OF PERMIT
POOL AN —NOR +RPA
IN,VEG"CION
POOL ANDIORSTA 15, noo. no TZ
XMNAA TE1114-^ Tf %rA1rr1J1Wrr�41T1'%N1
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igAii"A
0
FEIRAUT FRE 801101,kRY
PLAIN CHECK KIM
C WRTIRWnIONATE %
I-11LECTRICIV. FIM, __ POOL 60 1 0 f, 1%
PLUMBING ME— 1"X 1.01 _000_4194M
,lJq-'T,MALCO'NFCRfJCTIONIA,Ntv)PI. UNIMIRCK
*11319 �n
I.X3.3, PRE -PAID FEES
$1.00
ITOTAL P'CUMIXI'VEM IMPENA"M
RECEIPT
DATE
By
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
I DATE
I INSPECTOR
OPERATION
I DATE
I INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
ExhaustFans
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
I
I
Final
I
Final
POOLS -SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
I I
Underground Electric
Underground PIbg. Test
C.4o
Final
PLUMBING APPROVALS
Gas Piping
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
ShowerPans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
-3
COMMENTS:
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
Utility Notice (Perm)