0211-106 (RER)LICENSED CONTRACTOR DECLARATION
'r hereby affirm under penalty.dperjury that l am licensed under provisions ofd+
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
7.43371 �'.J '.,Y ZtC . l 1/0. -
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.
Sx(fi�rr) I have and will maintain workers' compensation insurance, as required by
ion 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 :1�«"Li�l'1�.Fapt 2AtLtg+ Policy No. 1-9%%4.92(3.
(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 of Section 3700 of the Labor
Code�,l `shall forthwith comply with those provisions.
gab: 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 representatives of this City to enter upon
the above-mentioned property for inspection purposes.
dignature (Owner/Agent) Date
BUILDING PERMIT PERMIT #
0211- 06
DATE'J� VALUATION , LOT TRACT
1
ADDRESS 7a{ 1 7l.:tiiA rMC, 1i r0 JOBSITEAPN
OWNER
CONTRACTOR / DESIGNER / ENGINEER
:NhJ .DAVS:tkMES3Ci
LAQUANTA, -CA 92253
YUCCA. We Lxxiy CA 92294.
.(169>365.7838 C„B h 28111
+
USE OF PERMIT
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P3?(i !'iP('lliW&D PIJAMS.
VALJUNFION Lo-
ti
ESTMAIED C06f QF COINUMUDON
100 Awl AX)
PLAN CHWKYU 101 -M-439-2 .418 MIMS
WNST.RUC TION R-2 101-000-418 -000
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NT}t+ONE;id14C1'1'ION P73fr'.• RZ-311) 101-00044,1.000 �tQ.Qti
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RECEIPT
DATE
BY '—(_
DATE INAL
INSPECTOR
') i7
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVAL
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Roof Deck
Combustion Air
Exhaust Fans
O.K. to Wrap
_ 3
F.A.U.
Framing
Compressor
Insulation
—Z - S
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wail Firewall
Exterior Lath
41 -2 y - -3
Drywall - Int. Lath
-
Final
/
Final � -
BLOCKWALL AP ROVALS
steel
POOLS -SPAS
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
% / 3
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)
ELECTRICA APP OVALS
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 42 4 10
Utility Notice (Perm)
COMMENTS: