0304-186 (RPL)' '�•'.
- •+� LICENSED CONTRACTOR DECLARATION �_ a
-186
- I hereb affirm under penalty of perjury that I am licensed under provisions of t ,°BUILDING PERMIT PERMIT#
i. Chapter 9 (commencing with Section 7000) of Division 3 of the Business and � DATE—VALUATION $115.0w..00LOT TRACT
04 W Professionals Code, and my License is in full force and effect. /�/ ,
License # Lic. Class,.. Exp. Date '
r- O 6906>45 B131C,• t4 ESFi�1IC►� ADDRESS JOB SITE 5(, 155 1. o,`� i?liifhi� '���!�AT?t� APN 7d2;➢af1-EJki7
t`
0 Z Date ���-A ^,;Signature of Contractof LLJ
OWNER CONTRACTOR /DESIGNER / EN INEER
O.� % /
� � o:
J U CID OWNER-BUILDER DECLARATION PODOX810 1,125 j 'LfXWi: i3i;s'i J iVP'.
W WWI hereby affirm under penalty of perjury that I am exempt from the Contractor's cr.
QUI. TA +«/. 2'�5:a i�lKC`:'� J p Z .yCj.,q
U) License Law for the following reason:r
Z_ ( ) I, as owner of the property, or my employees with wages as their sole �fy V)2.5 �-i65.5 CE 4990
compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code). USE OF PERMIT
( ) I, as owner of the property, am exclusively contracting with licensed � (De,)T..":A.1IDpC57ZF1reA
contractors to construct the project (Sec. 7044, Business & Professionals
Code). JL.Sy est,?�:s.,xrYsa ;Utu cad. .vr,�i►�� rare i �rs�".��r.►iv
ce)() I am exempt under Section B&P.C. for this reason PT,40Z 9'!. .PRE-11UUTEER j�`PDI`'• fON. EQUjP�� NT, f7,'9Q A',,r`UrU* 1KY1,
O N Date Signature of Owner 1110 UTWil
rn
Q WORKER'S COMPENSATION DECLARATION
LO Q Z I hereby affirm under penalty of perjury one of the following declarations:!:ijlrldAl%�fOiT 3p.r i $:1UA LIS
r FZ O () 1 have and will maintain a certificate of consent to self-insure for workers'
X W LL- compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
M Q () ( ) I have and will maintain workers' compensation insurance, as required by
O C) Q Section 3700 of the Labor Code, for the performance of the work for which this
0)H permit is issued. My workers' compensation insurance carrier & policy no. are:
1q4_Z Carrier `i;9i`1',.;l.FUND Policy No. 1,1V`0150-Ir1 ?�?�Z7TA+NF1`Ik�l't�oS�Li�+'�°C��?�J ��Y°ia.41�'P' 2�U�ti?.t?l7
°D CY
rPERAnT YT,.19: NT1i1%? S9 ciY
Q (This section need not be completed if the permit valuation is for $100.00 or less). MAN CIl~3Y'VI «TTE "11011 _00Ch439a318 V11_4•a"'ao;
J ( ) I certify that in the performance of the work for which this permit is issued, (IGNMRlSti,'! IGNx FRE11 W1 00-418-000 1162.11(?
I shall not employ any person in any manner so as to become subject to the�y1' r,,•j '.1CM1YKE-^ P(M 101°-000w-121-00 S24,41
workers' compensation laws of California, and agree that if I should becomeLC,:�i.'�'RlC�,:, trf •• R'f30L iOF-1.1'1'10.41 0-041 $•',3,8
subject to the workers' compensation provisions of Section 3700 of the Labor PLf3hg1�E3di )i'f+l'.•. 4k�"�O). T rJl �L1fi<9] 3-GJO
Code, I shall forthwith comply with th se pr visions.
Date: i , Applicant / � +
Warning: Failure to secure Workbrsr Compensation coverage is unlawful and %
shall subject an employer to criminal penalties and civil fines up to $100,000, in DLAPR
[�
addition to the cost of compensation, damages as provided for-in Section 3706
of the Labor Code, interest and attorney's fees. 18 200 •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. CITU OF LA QQUINTA,•
1. Each person upon whose behalf this application is made & each person at LTi ix:)`t Yi) t�j, �{� .y `'. ,: "° ; • - , ' `n I- " ti:46:i.;�0
whose request and for whose benefit, work is performed under or pursuant tos.. ,+30 :k':f X-PAU)171-'O T0100
any permit issued as a result of this applicaton agrees to, & shall, indemnify ',• w1A,
& 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 3.%1�l2. EJMQ ',, �:_ Z81DO1.,1NIO l!
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 d'nspection purposes.
,� f{ E RECEIPT DATE ! t sBY DATE FINALED INSPECTOR
-Signature (Owner/Agent) ,'{{{ Date �" `` �1��.�,� — �-"
INSPECTION RECORD
OPERATION
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
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
BLOCKWALL APPROVALS
POOLS - SPAS
Steel .� -2s- 3 5
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
`ftste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX 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
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: