9705-102 (RC)LICENSED CONTRACTOR DECLARATION
CI - I hecbo affirm under penalty of perjury that I am licensed under provisions of
F— f Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
cel w Professionals Code, and my License is in full force and effect.
p :) co License # Lic. Class
Exp. Date
� � d2zB .Ei �^ t/ yy%Z�i39
ZO � ate Signature of Contractov '
U' 0) OWNER -BUILDER DECLARATION
LU LU 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).
co () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
ON
0)
Q WORKER'S COMPENSATION DECLARATION
o cr I hereby affirm under penalty of perjury one of the following declarations:
O () 1 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 J Q performance of the work for which this permit is issued.
ED Q U ( ) I have and will maintain workers' compensation insurance, as required by
Ou Q Section 3700 of the Labor Code, for the performance of the work for which this
d a Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
°�D Q 17-xE'Nfl'' It0It4 ON 11"T. ,L,
J (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,
Ahall not employ any person in any manner so as to becorr,tp- a subject to the
workers' compensation laws of California and -a fee that }" 11 hould become
3 subject to he workers' compensation orvislon of Sectio 700 -of the Labor
Code, 1 s all f hwi h comply with those ro"v' ion
VDate: Applicant y /'
v
Warning: ailure to secure Workers' Compensatio 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 laws relating to the building
construction, and hereby authorize re re en3ativeS of this City to enter upon
tt e above-mentioneproperty/for
, in t o�� poses. i
�'O'glialuie (OvyiieiiAyeril lel+ a Date f
/ WY-' ✓Z
VIV
BUILDINGPERMIT " PERMIT #
CONTRD #
'ri►s �E�x
516 5
DATE ,V191197 VALUATION - �y � LOT. TRACT
JOB SITE
ADDRESS 78.144) CALL)h %'aU1�1�'liCO
APN 769-030-042
OWNER
CONTRACTOR / DESIGNER
1.1" P,0C 1,+MyvERS
{/ENGINEER
vTSpi1� .11���. I' �.r lYi. �"K. i.. S.li•`a%s 1,. -
I_34 PARK VIEW AVF 024ti
rtM�;S I;1SE hiHc�1VEl� U1t.
A1f1NHA"ITAN W,.''AC'H CA v(:
LA QUINTA CA
92253
('7fa4,17'71-Ilfif)
t�'131'.# ::R?l;
USE OF PERMIT
�U: :t.>~,� Iv3ii i J:; 'i ls'fvwN`i f iv c�ltSJVCi� t�ivi' : i�t:r A'i`! AeftLU E LAK
V ALUilf'1GN :,tit' OkO L3
ES e',MA`� ED WIT t.3I+ i.�.ra�iT�iri{.rls.7i ai0IN
`'j�.y qry
y g�Hn a ��yy,, �`I �jy. SU
F�1'.7�M Fill P,VIC SUNI:fil AR )' As,*
PERM
PLAN Chi1ft'fs FEF fill _(M•-43y-3IR $46:104
£•l:i1J '1lr?lid"t'9f1N F`i i? 10 i_000-4j)i-i"
L1.,}i!.;'1`itti'.1L1'#ila 10i.:?7t��120-f3()A :3tl.tii0'�
Cn
e
t,
e
LESS. PR -1'r ID ITTS
so cl{l
'DOTAL PERMIT �')0e,8 011F, (�i�}W
$141-90
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS -
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 8 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
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
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)
CITY OF LA QUINTA
SUB -LIST
:0NTRACT0R / _ ADDRESS.�(zAL��_k
)WNER ��✓ JOB ADDRESS7XjA2 jkz o -� . ,
'his form shall be posted on the job with the Building Inspection Card at all times in a conspicuousIR ace.
: is the responsibility of the General Contractor or the Owner/Builder to monitor the sub -contractors that
re on this list are the same persons performing the work. Any changes to this list must be approved the
;ity of La Quinta Department of Building & Safety prior to work being performed by a changed sub-
:ontractor. Failure to comply -will result in a stoppage of work and/or the voidance of building permit.
TRADE
SUB -CONTRACTOR'S:
NAME:.
TYPE. OF
LICENSE:..
.
STATE'
CONTRACTOR'S
LICIr11ISE.
NUMBER
WORKER'S'`
:: COMP NAME/ .
NUMBER: ON FILE::".
CITY
BUSINESS: -
LICENSE
NUMBER!;
EXR. DATE
GRADE/_
EXCAVATE:...
A/C -12
PIPELINES
C-34
CONCRETE/
FOUNDATIONS
C-8
ASPHALT: ::..
A
FRAMING----,,-:.-
B
STEEt.'
STRIrC iURAL
C-51
A'
A /M
c�
C> ^�
MASONRY`.
C-29
PLUMBING'
C-36
LATHING
C-26
c�P La4�a , q7
DRYWALL
-
PLASTERING ::
�j
C-36
CA ci::_ 100 1 IWo l
7Y-7 �
HVAC
C-20
ELECTRICAL
(General)
Ca"4"VQ
C-10
ROOFING.
C-39
SHEET METAL
C-43
FLOORING.
C-15
GLASS/
GLAZING
C-17
INSULATION
C-2
SEWAGE DISP.
C-42
DECORATING
C-33
TILE
C-54
CABINETS/
INSTALLATION
C-6
FENCING
C-13
LANDSCAPING
C-27
POOLS
C-53
OTHER
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BUILDING & SAFETY DI&E-PAA-f
CONDITIONALLY
FOR.CONSTRUCTIO N
ACCEPTED
INSTALLATION AS PER
SUBJECT TO
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AND ALL 'F!l LIC)�ll BLE CODES
BY
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