9807-128 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Cl) Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
C14 W Professionals Code, and my License is in full force and ffest.
O =)M License # Lic. Class 1 xp. Date
I � 1 407 8 f 1/,1}09.)
oZ r— Date /�� Signature of Cont`rracto
(O 0- i
J U � OWNER -BUILDER DECL ATION
Ha rl- I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) License Law for the following reason:
Z_ ( ) 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).
ce) () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
ON
rn
U—� Q WORKER'S COMPENSATION DECLARATION
o z I hereby affirm under penalty of perjury one of the following declarations:
Lo � O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W tL 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 U (L/I have and will maintain workers' compensation insurance, as required by
O 0 Q Se tion 3700 of the Labor Code, for the performance of the work for which this
Il 0)♦— permit is issued. My workers' compensation insurance carrier & policy no. are:
Z Carrier Frr� A ryy Policy No. 1.0"110W
��¢
Q (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' compensatio/provisions of Sectiofi '3700 of the Labor
Code, I hal fortAwith comply with those pro isions.
Date: f ! ��f Applicant
e
Warning: Failure to secure Workers' Compensati 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 representatives of this City to enter upon
the above mentioned propefor i
spectib?n1purposes.
Signature (Owner/Agent), �\( Date'" 5/
BUILDING PERMIT PERMIT 7/
f "1}7- 11 ata
DATE % VALUATION LOT TRACT
4, d tilt Si.$9,6S9.4ff 9 2Sl ti l
JOB SITE
ADDRESS 40-235 RIO ARMOSO
APN
G�i6-33 i^t!a!R
OWNER
CONTRACTOR / DESIGNER / ENGINEER
►'.d I.; Li '4` °,� ' ?LO:'t��f: i�:t{
tits, RMS CON's,`rKlfC nam
P.O. Box 1 If 16
719293 RF1:NC::T40 Lel QU1NI-A DR.
LA6?tJIN'TA CA 9.2253
LAQIJIWr.A. CA. X253
r'.
(700)1714941 C13LIf 2990'
f
USE OF PERMIT ;
;3.1 i) - i.? >.AN 2-2 I'RRM:3:T DOrISNOT WLU OR
k,i;w°Ci Diva. �:'t )syi:si .i3u"i [R,rid
Gd11RA(s t/Co .€2PORT 41100 SI'
LS .I.Aliiyh9..Il,cI 4 tM OF ✓V;11'Ira9.0 .t�fJi.. s k�M,./ \t
137�i/e.. .�Vi}
d �,�Pi�'lTit�.,�'%t:1N.i�L•'F }.C4f-dDC?(U-Iii^4C1f3 t.�+9
t'LikN (,fl;1;.'Ie 11-1Z If1l�( ►-1;4? :'1R ?^e().wl
t\ 4E.,C.'I:IAN'tCl4),rc"13 IQ1 C3t?[I �lR,t-t36I(3 ,. $79,00
i"al..fst.� t'lLl�„t1.f, .i�,ts I G } •Uit�'4.ir1>t?i)fl �5 41129.35
P1,i.IA96itdt i+ :1r 101-ODO-419-07100 lt7 $143.25
n'1•tt�`at.�h��'cic�T�:1r.t2_�;!!� Efl!-t1�x4t-t�N? �tt�.�"�
011A1 IDI Mr -1 $ :.94-0M-421000 Sa�atx►
IR Ro;-,'I r 0U7.1; ru" 22 "tM)-443-141 $3,8.1.7, 6
ikl[C1' IN P0131.1C" KAt t3`d - R1 SIC, 7014 - +5-wo
�` ; t? 1 I�jri >i� t;C► f.J� "1'ic R� tti 1n r,11AN CHL) K z*
�ti,Q�Ka 89
-1"5 1'.} r.,;Vir P:1�};S
Vit! t)tl
-� l'ai'r./; 01FRIIIIIII'I' 4MS DUR NOW
$5,984AR
J
t,
RECEIPT �-
DATE
By
DATE FINALED
c
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade 1,2
Return Air
Steel
Combustion Air
Roof Deck — —
Exhaust Fans
O.K. to Wrap —
F.A.U.
Framing
Compressor
Insulation .22_�c,
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath — �G
Drywall - Int. Lath
Final
Final -og ac
_
POOLS - SPAS
BLOCKWALL APPROVALS-
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines — D
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection d
Encapsulation
Gas Piping
Gas Test
Appliances
Final
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) 5 Zp_