9905-007 (AR)N U)
W
Ouch
P— 0 _U.)
oZ
C0 OO
_J(~jCID
W w
F- a ..
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
v 6aD to J' "' 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).
( - ) 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.-
( ) 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 Policy No.
IN. tcol 4.),i 'x11%
(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
subjectrto the workers' compensation provsio'ns of Section 3700 of the Labor
Codd, J.shall forthwith comply with those provisions.
VDate: 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 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 applicator 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 proerty for inspection purposes.
NSignature (Owner/Agent) F�{ J1 �1 Date
BUILDING PERMIT PERMIT#
"05-uu7
DATE j VALUATION S.53,9(4.40 LOT 10 TRACT 29003
/f
JOB bi it:
�x
ADDRESS 9 % �iN�r: 3 iM eri\
APN 76.9-5140-002
OWNER
CONTRACTOR/DESIGNER/ENGINEER
ryrar rr�s crtr ¢� c.Pu >r r° ter enrrl
h�ds4J k-* 4 t4. 1.1.l .l.,tl.-.AA A A %r4" 11. r1,,..
a IrlT e r� rrrr,.�+,r r vti 11 f't tr.rn
JAS. 1,, 11.6 .144111_ .1AI..11* es Ai S A LJ.. I-1 m' AI.•11".
1 PI65 P011KIIDrUl.>LIVIR, .i,.Cnk
12a6, Pl,dl�'I'rt Da N.uktt surm 200
)JUL MA.k 1;:A 9201 -Ni,
$') DEL a'lfAR CA 92014-38-'
USE OF PERMIT
LOT 110 .PI,AN- 2,02 -PENNUT ;I-Y(YES NOT L1VC L I.O11
f%0C:`K W.ALLN r012 Fri iC?t... * 7 /6 ".PLAt4 CFIttii�,'K 1-'U? i`2VIXIc:'E'ION FOR
fti:fJc.rtr PLP IS UADYCE C'JF :SAW PLAN'VYPH.
Cll s'l'4ab3' +tY:i:C.f2�S�:"E it'ai�3 1 +11130 SI
I jj {��,Y
RMT FEE
CiC.0N '�';r.ZtP:. 3'?0'N FEE :1:01.-t)COA-18-d)13f3
FT1;$25 13
1IECT'1ANIC L F1111 I0.1 t1(k"��121 f)�1`.1 S6.50
fill rRIC.A L I A,11 101-000-4i€t-G 00 $15.:6
i'"I,t ril9l3[i4t 3 i »;1i' 101 -000-4W-M) 540.00
8 .'it; NO 1\40110N N FQF - R.E810 100 ( 4M-2*41-OPO $340 .
f,'dir3€a`:;:; MMU'r111Uttl .Ml 225.000 -443.3 -►2. 3667154
ART 114 .tft IV.1C PLACES - fitis4;M 701.000-25-5.000 W.91
�"U � 'Klan. `;:S INS,"''[ tJC T .A I. ,r N 1;4i .C;
13ta1 74
TOTAL t'aF1UA41T .Ff"E'S DMI, t�ft�t1�?
$961.74
RECEIPT
DATEBY
DA7VFINAL
INSPECTOR
I
INSPECTION RECORD
OPERATION j
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
0. 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
BLOCKWALL APPROV LS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
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
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
Utility Notice (Perm)
COMMENTS: