0009-197 (BLCK)I LICENSED CONTRACTOR DECLARATION PERMIT#
hereby affirm under penalty of perjury that I am licensed under provisions of BUILDING PERMIT
F_ Chapter 9 (commencing with Section 7000) of Division 3 of the Business and DATE VALUATION LOT M)9-197 TRACT
C14w Ffofessionals Code, and my License is in full force and effect. (ia"f
License # Lic. Class Exp. Date
oCY LO JOB SITE APN
; 7�tt317'P C29 s ;0 2C ADDRESS 45-425 COLI)`�ROO.KLANE
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Z Date Z ' G� Signature of Contractori� OWNER CONTRACTOR/DESIGNER/EN ENGINEER
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� OWNER-BUILDER DECLARATION "ARCHER Ci° ER It:ir�.�'�Y MASONRY
LV LULI I hereby affirm under penalty of perjury that I am exempt from the Contractor's 4;5-415 COLD—BROOK LANE 4796 CAMARUJ—A,A%geNLIT:
~ U) License Law for the following reason: LA Quaxm CA 92253 YUCCA V'j3,II.E'y CA 92284.
Z ( ) I, as owner of the property, or my employees with wages as their sole (7601)365-:33 � 3 CBLS ` 43.7 J.
compensation, will do the work, and the structure is not intended or offered for d
sale (Sec. 7044, Business & Professionals Code). USE OF PERMIT
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).f' ' 01, F. 6'f-1 OARDEN �`+PALI, • O'IZCO ST.AT� D!'�RD OTfi. Y AS PER, APP!t.ZiVSD
O I am exemLIDpt under Section , B&P.C. for this reason ?
O N Date Signature of Owner `f flS.t.NS 023G
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d Q WORKER'S COMPENSATION DECLARATION
p Cc 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' <.6 FT. WALL 2�,�Q LF
X W 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 ( ) 1 have and will maintain workers' compensation insurance, as required by
O U Section 3700 of the Labor Code, for the performance of the work for which this
Z permit is issued. My workers' compensation insurance carrier & policy no. are: o
CarrierPolicy No.
co 5 N'TA.TE FUND 229-00-0017217 1 ]ES1UWrKD CO.Vr OV C009JE1 CION SWJDO
CY V iii JOY SUMM Y
J (This section need not be completed if the permit valuation is for $100.00 or less). C CSf! RUt't lOid PEE 1.01 -000A41 dui DU $IS,
( ) 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 Califo�a,„and agreetthat if I should become
subject to the workers' compensation provlslons,” of Section 3700 of the Labor
3 Code, I shall forthwith comply wit hose provisions./;
Date: �' 2. Applicant �(� f �L
Warning: Failure to secure Workers' Cfompensation coverage ig 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
fog, 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 KM-TMAT CONl3'S12'0TOTION AND PLAN OW-CK $15°0(1
any permit issued as a result of this applicaton agrees to, & shall, indemnify 1 „:3 PRE-PAIDFly $0,00
& 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 TOTAL 1%R Wr TIVES DVE NOW V&w
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-reed 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. �represetntatives of this City to enter upon °
the above-mentioned property f r inspection purposes.
RECEIPT DATE BY DATE FINALED INSPECTOR
Signature (Owner/Agent) ���. Date G'
ON
INSPECTION RECORD
4
'i OPERATION
I DATE
I INSPECTOR
OPERATION
I DATE
I 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 - SPAS
BLOCKWALL
APPROVALS
Steel
Set Backs
Footings�p
2 C�
Electric Bond
Main Drain
Bond Beam
y
Approval to Cover
Equipment Location
Underground Electric
Final
�t
(0� `
Underground Plbg. Test
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
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
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)
�F Y OF LA OUINTA
BUILDING & SAFETY DEPT.
1 APPROVED
FOR CONSTRUCTION
DATE By
A RE -INSPECTION FEE OF $30
WILL BE CHARGED IF THE APPROVED
PLANS AND JOB CARD ARE NOT ON
THE SITE FORA SCHEDULE
INSPECTIOIV.
NO Dcan ONSE