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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that* I am licensed under provisions of
Papter 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
C5 (W I I /2CA
n Signature of Contract 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:
( ) 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
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 COM PENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
( ) I have and will maintain a certificate of consent to �elf-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.
(x) 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.
-1 . 4 If 4 �4%
114DU I ilk 0�
1
(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.dalifornia, and agree that if I should become
subje�t to the workers' compensation provisions of Section 3700 of the Labor
gode, hwith comply
,,Date: Applicant
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 s et forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose requestand forwhose benefitwork 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
�vork 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 thebuilding
construction, and hereby, authorize representatives of this City to entercupon
r inspectionl, Urposes.
the ab6ve-mentioned pro� ity fo 9
108/ignaiture (Own Date
PERMIT#
BUILDING PERMIT
1%
DATE o. VALUATION LOT TRACT
JOB SITE 7�
ADDRESS 79�025 BICHORNTRAIL
OWNER
CONTRACTOR DESIGNER ENGINEER
f-,, Ivor,
,47,95 ; iWY i I I 9,-i' W5
P.O. BOX 1,n)i
INLAAN WYL(,S % t_1A 92.H0
I.A QUINIA CA QD�3
(76011W-l',R'S 1945
USE OF PERMIT
KX)L, 1'040.'Ok SPA
[ICN -4. '�, SPA ONI,,Y - ALA1W&BkRRtE_R5 USHAJI BE 114 PLACE AT
001. iV4DX_A% FA
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'A T
eCRAUTFE F. NVAIMARV
K",�t4 cHyr, f, vfy. lot -m-439-318
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MKIIAMICAL I'M — POOL
ULE-C'TRICAL J1*a-'-- KKA, I (i I _050 _42104M $4 S. 0k)
PLON110NO f."M — I"_)L JokAx)-1119-009 SIV,(xi
C 0N'ZZT'RTK'0()N A] -If) 111,AN r.J,lIJCK
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LESS PRE-P)MR.P.13
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RECEIPT
DATE hl�BY;
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
7-7§ATE
I INSPECTOR
OPERATION
I DATE —TINSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
steel
Combustion Air
Roof Deck
Exhaust Fans
OX 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
BLOCKWALL APPROVALS
Steel
POOLS -SPAS
Set Backs
Footings
Electric Bond
Main Drain
601 1f,04—
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
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
ShowerPans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Zo-EME
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
UU14 Notice (Perm)
COMMENTS: