0310-294 (RPL)LICENSED CONTRACTOR DECLARATIONgUILDINC•PERMIT PERMIT#
I hereby affirm under penalty of perjury that I am licensed under provisions of4"-'ISS
I— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and DATE VALUATION LOT TRACT
04 W Professionals Code, and my License is in full force and effect. ,&f3O119t�(1�3 f�Ctd3>fi,w
p =) M License # Lic. Class Exp. Date
I-- CY LO JOB SITE APN
1` UJIQ' t: )t i> ('153 ks3.L: �.3`�%? 10#it:)I ADDRESS
78•-3-75 COYOTE C'.AN: 0N, 6`:iiQVr r
' / I
iM .� CONTRACTOR / DESIGNER / EN (NEER
Z � Date � �-' Signature of Contractor—� �"� ,� " � OWNER
cDO�
r` aY�4 VJ.�:S'.A�'��'i��`'�OPE V�3.'M r'�3.�C.k`: I��..,11, EI S ti c':,}CS.I.� � ra�`E`PI YC"Ie' r .I'd (, R
J ca OWNER-BUILDER DECLARATION _ �
LU W I hereby affirm under penalty of perjury that I am exempt from the Contractor's F02,07 1144, 1815'1GrIll Affi"UM1 .)4
~ U) License Law for the following'reason: LA flUWT& CA 92253 CA 922�6
Z_ ( ) I, as owner of the property, or my employees with wages as their sole L`% ., )se, 9,.?n mix
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
POOL AOR 43 A
contractors to construct the project (Sec. 7044, Business & Professionals
Code). 'ir`i?.&i' OW r "ZWA UU AT XN R Y, 19- f;?NA&P On- I, Ujs
C'`)() I am exempt under Section B&P.C. for this reason
N Date Signature of Owner
O0
d Z WORKER'S COMPENSATION DECLARATION
o <
Q �C�t�cl�lFi.} •CC I hereby affirm under penalty of perjury one of the following declarations: BRA, i "Ij13 12
r F2 () I have and will maintain a certificate of consent to self-insure for workers'
X W compensation, as provided for by Section 3700 of the Labor Code, for the
O � Q performance of the work for which this permit is issued.
m Q O Y have and will maintain workers' compensation insurance, as required by
O U QSec i n 3700 of the Labor Code, for the performance of the work for which this
LO I— permit is issued. My workers' compensation insurance carrier & policy no. are: I
.0 ? Cb Z Carrier STAT �'•t.'.tNAPIST14GATI Policy No. U4.6.p§c+8.2003 h39:'�P.in'�,:T:1�D ��:�.',.� 01�' �"�`���r!"r- �.�0 7101ti1
J (This section need not be completed if the permit valuation is for $100.00 or less). PILIM CHMI•Y, rZA F R!7.000,4 16
() I certify that in the performance of the work for which this permit is issued, C01:73r1•RUCTION 479E 101.000-41,78-015'0 ro
I shall not employ any person in any manner so as to become subject to the E'L•.K."TRIC.M. FIKE — 1100140 1. 0 1-M10.4100(? $43.00
workers' compensation laws of California, and agree that if I should become
3 subject to the workers' compensation proviIons of Section 3700 of the Labor PIA38P114f3 "` P040I, 107 "000.419—M.) g'r1l ,f e
Code, I shall forthwith comply with those • ro�visions.
Date: .-1 Applicant
Warning: Failure to secure Workers' Compensation cotiierage 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 OCT 2 8 2003
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety CITY OR.LA QUINTA
for a permit subject to the conditions and restrictions set forth on his, FINANCE DEPT
application.
1. Each person upon whose behalf this application is made & each person at W. 3„5'Obi'A4,MwSTRR. M'10)4.A.W ,+ ��b�r ��l.CEEC.
whose request and for whose benefit work is performed under or pursuant to . . �� �,1,,.?, p j *` S,1100
any permit issued as a result of this applicaton'agrees to, & shall, indemnify Ix,! " ' AY } MEN;
& 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 --Anm,YmmmITmm;`;va::?s`%'wo?cy'
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 17,
inspection purposes.
L(
/�RECEIPT DATE ' BY D IN / INSPECSignture (Owner/Agent) 1"-� J f!y• . f. Date�f7-
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 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test -5
Final I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
ehower Pans
O.K 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
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
78375 Coyote Canyon Ct