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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.
License # Lic. Class Exp. Date
690645 B 003 20i
111Ja e,f�p/�9 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 -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:
Carver Policy No.
il'vS OF 173; 671TI wi:,e.A 7,004 0,40
(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
subject to the workers' compensation provisions �Pse tion 3700 of the Labor
Code, I shall forthwith comply with those provis• = s
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 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. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize repr sentatives of this City to enter upon
the above-mentioned property for insp tion purposes. J�
Signature (Owner/Agent) .Date,
.
BUILDING PERMIT PERMIT"65
DATE VALUATION. ,LOT 46 TRACT � �� i
JOB SITE `� �G�
ADDRESS U-141". �s��i;�a.l�.+iN%�i�%WE DRIVE,
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
1425 E. LWIVERS£N ORt"> E '
1475.E. Uhf VERMY DIUVE
PHOENIX AZ M34
MCIENIX AZ 950-14
€2x)?5't"-Eii S f;'i3IA 1490
USE OF PERMIT
S.{.`hft LF.. fF31.MSe`Ar DWRLUNF6
`iD- LOT 44,11 -AN 4R w P-110411' DOk NOT 1"Nd 06 BLOCK W.AL L, 0:1.
PCXYL. 7; Ste Mi;f4"# ION ON VL M4 (.11F:CK 't;`WE, FOR, 3SSU A,NCY:
10F StlN•11~:MAN TYPE.
CoNsri ucvirw 1,984.00 151.
voRC1VPKrxo 77.00
IGARACOCARP-OWF 483-04 5F
"Wr or
IC 0 NS �'it U' C i X.)N FEE 10140-4W-O(A) W -O(1() $8 70.5t!
Fel, ttW t °�i@',E: #�, Ohl~ 1 f i f • 1!f}fi-:13�?- i� R $17770
;41Tit:.TIAN1CAL Y41M, Will()
EL W M LC AL P FE -100420,0W
P1„ t.ft+vflvliiVt 6 F -El 11)1-t1Oi1�� tS' Cat9U i5't,i )
S"1•`lic'iNG IVICY-M,Y94"{"lri: ,, 4V rft 101,4f,W?41-fM, Tih 110
(.11ZAT;fldsTO ;:•"F:M il.G :)ti(? t9?3-Ob0 S:C1.lK3
Ait'i: IN PUBLIC P1.:f1t .c� •• HE481d 70-000)-.255,000 51 2.51
931�VA�:i,.E:^k�'� r14�iE�li�i:1'1r;t�,},i $1>i+1'r7.lkr
A. D PLAN r i f'is
'413, 50 % 43T
iej< S -S PRE PAID FEFS
50.00
TOTAL PERMIT 11TV-S DUE NOW
sa.S07M
RECEIPT
DATE
BY i
f
DAT I E oo
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings ! /_
Slab Grade C l
Ducts
Return Air
_
Steel
Combustion Air
j _
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing ^-
Insulation j�2_C�=�
Compressor
Vents
3—�k
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath f 2 , 2— 6k
Finales
BLOCKWALL APPROVALS
Final
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/(/ y = %�'G�
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral _ /A
Sewer Connection �Z) i v�
Pool Cover
Encapsulation
Gas Piping
Gas Test GC/
Appliances
Final
COMMENTS:
I
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 Ldoe
110S.0—
UtiBty Notice (Perm) C(/