9908-112 (BLCK)LICENSED CONTRACTOR DECLARATION
heydby affirm under.penalty of perjury that I am licensed under provisions of
•1- " Chepter 9 (commencing with Section 7000) of Division 3 of the Business and
04 W . P.rofessionals Code, and my License is. in full force and effect..
O =) .License .# Lic. Class Exp. Date
W in, 333193 C-?) 0 7131119,
c Z r• ate, Signature of Contractor ,
co O. '
J. U OWNER-BUILDER.DECLARATION
W LU I hereby affirm under penalty of'perjury that'[ am exempt:from the Contractor's
License Law for the following reason:
Z ( ) 1, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and, the structure is not intended oroffered, for
sale"(Sec. 7044, Business & Professionals Code).
as owner of the property, am exclusively contracting with licensed
contractors, to construct the project (Sec. 7044, Business & Professionals
Code).
M O 1 am exempt under Section MRC: for this reason
LO
N Date Signature of Owner
ON
C)
a Q WORKER'S COMPENSATION DECLARATION
p I herely,affirm under penalty of perjury ,one ,of the following declarations:
Fa.. p O I'have and will maintain a certificate of consent to self -insure for workers'
X LU L� compensati64, as. provided for by Section 3700 of the Labor Code, for the
Om J Q peript� " r�oepf the work for which'this permit is issued.
Q and will maintain workers' compensation insurance,, as required by
O "9�' a S sin 3700 of the Labor Code, for the performance of the work for which this
a 0)I-- pe • "Is issued: My workers' compensation insurance carver & policy no. are:
Z Carrier Policy No:
*IT 1 'n !11 1'!rl-1`I '1; i' fA7 J'4d<'+.
1'f��.i t�1LtA�.4� ��scy iGit., 4i J.J yY.1j:�
Vg (This section need not be completed if the permit valuation is, ,for $100:00 or less).
O 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
3 subject to the workers' compensation provisions. of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date: Applicant -
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employerto criminal penalties and civil fines up to $100,000, in
addition to the cost compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees:
IMPORTANT Application is hereby made to the Director of Building andSafety
for a permit. subject to the conditions and restrictions set forth on his.
application.
1. Each person upon whose behalf this application.is made &each person at
whose request and for •whose benefit woik is performedunder-or pursuant to- - -
any permit issued as.a result of this•applicaton agrees to, & shall; indemnify
& hold harmless the City of La Ouinta, its officersi agents and employees.
2: Any permit issued as a result of this ,application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
• correct. I agreeto comply with all City, and State laws relating.to the building
construction, and hereby authorize representatives of this City to enter upon
the, above-mentioned property for inspection t'i n pses.
-. 910
Xi nature (Owner ��77-- -4�.'- -
/Agent��e Date - 7
BUILDING PERMIT PERMTrr
DATE VALUATION ��1.4y LOT' TRACT
JOB SITE
ADDRESS S'� �➢ SQI !UarI.. �r:�R �� �}Bi
APN r
OWNER
CONTRACTOR 7 DESIGNER / ENGINEER
i.YJIU�'il;i1
k still l.l+ 1.
C g, IV,I!"E "'Y" j�r 44 ,�,�,•�aY�.C•,
N. A. � 11�: L. l� .J•. r L <
32-4250 DEL GATO DR
-in:? V[SEA:DEL LAG(N
LA QiA1VTA. CA '':53
V ALN1 f3E+iENT {'A
GUIL'o" 5503
USE OF PERMIT
3W4L[N i'•( C#F 10 E'TiUrI.1("KA&,+i~+;3"RET AM 6A4Ci./li6 W ALL — -
2rU LIN FT OF 6 FT OAD'.!.'EN W.tAt..s_.
AU.
- u:=�. • -yQ,i r �Y•tr•e�l r"�rzgro• vw• rr'rl�Yr;s�e•s rra'•+•riro'
' , tie r � r.lr'Ynl A CLhr >•,k„s:D.d �s.Yf• �.a.>'.1 rN' o � u! r.. A s.e.r �
,.) tc:r. rea
,•: a*s.!tr,eoxr -
FT"Ruff VC lil, XciUiiIAkk,
iti�t�r9�i.Ul":'I'tl�)[� fr:f�bs' ltil-LKi0-4A%d"•(}(1t} Silf,tF9.fidi
�;t•fR TCYI'jal,CON.-IT111fM°GINAND MAN ?-5r$CJ{r
LESS 'M13 -PAID FEEN
T(A'1•,ALI1"€';I•i_MPTF!T EIS DWIT"Ni.b'i>F
�k"b4f9t•.4Pit
RECEIPT
DATE
BY .
DATE FINALED
INSPECTOR
It' NE'R
L (i0 i � 00-111011\ A -AS -1,207' I\\4,J
' OPERATION
I DATE
I 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
POOLS a SPAS
BLOCKWALL
APPROVALS
Steel
Set Backs
Electric Bond
Footings
_ Z6—
Main Drain
Bond Beam lmvt tff_
Q? 57
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING P OVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
i
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
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)
8►' -0' fMA�C,? RVi. TRAr',T KhLL w,t 4'-0" MSE F.L7AIN11r'�i 1
A,,orABGM
VIM -,rfM
,
OIRW 6016 OR -Ma Mk'lI MK OC 4416 WIMP.
10 WH
0 0
l
1C'0r.�JRs. G
SRIT CLIS t+l WW OILS'
• ,
OIRW 6016 OR -Ma Mk'lI MK OC 4416 WIMP.
SRIT CLIS t+l WW OILS'
GINN
i 8 KAM
., GGr�PgORMs'O tEG �i-.1O!'y s 6O k'Sr;
7d�6.OF V KAU
9a ;
4:A 4
i I
O�GO b816.O1t 000 Homork BL0m 0A iSf61a SWMp
socac Suff 'AL: Deus
rLIAT r : =.V J041S'VF2 cotes
ate Roxt COQ PtAt,6.5
a�