0401-228 (BLDG)LICENSED CONTRACTORZECLARATION' y • PERMIT#
U) I hereby affirm under penalty of perjury that I am licensed under provisions of BUILDING PERMIT 1
F- Chapter 9 (commencing with Section 7.000) of Division 3 of the Business and DATE VALUATION LOT 9J5`'1 TRACT
CIJ LLLI -Professionals Code, and my License is in full force and effect.'
O =)ch 'License # Lic. Class Exp. Date ! ` '
t` CY U7 • - JOB SITE t, �' API LUN
r` Q' 'IiSCI 3J y /'��Ei" —•. ;� ,� 2'fi5 ADDRESS 81t 2 MIME NECOCKML.L�IS _ ..
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Z � Date!, -' Signature of Contractor OWNER CONTRACTOR /DESIGNER / EN (NEER
r— C) OWNER-BUILDER DECLARATION Ci:VC0i.%" WFIW A,%3'iiROOK i)L"i)EL40PAt1iN`i' COMPANY
LLl W r- I hereby affirm under penalty of perjury that I am exempt from the Contractor's 5140 AV'.F..NIDA11ZTC'71,TA8 5140 dsVMWi1fMTMAZI
~ (0 License Law for the following reason: CARLSBA y Gly 9200S CATjyMAD CA 92008
Z_ ( ) I, as owner of the property, or my employees with wages as their sole ('f 6i )£3t5�-6 6%3 MIA 3376
compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code). (P USE OF PERMIT MIT
as owner of the property, am exclusively contracting with license,
contractors to construct the project (Sec. 7044, Business & Professionals/ TrC)1`I.7.11ING
Code). 10
C0 O I am exempt under Section B&P.C. for this reason ?% t Y. 6' 131,UCX iffi.ALI,,, CITY STAN.DARI7
L
N Date Signature of Owner /^
ON
a Q WORKER'S COMPENSATION DECLARATION �r
C) I hereby affirm under penalty of perjury one of the following declarations
Lo IQ O () 1 have and will maintain a certificate of consent to self-insure for workeYrs'�1, Ari 614, WALL Y ip,00 ).k2
X W !!: compensation, as provided for by Section 3700 of the Labor Code, for the
m� Q performance of the work for which this permit is issued.
Q U ()) I have and will maintain workers' compensation insurance, as required by
O Q S ction 3700 of the Labor Code, for the performance of the work for which this
CL
0)H permit is issued. My workers' compensation insurance carrier & policy no. are:
Iq Z Carrier Policy No.
ao —) STATE FANO 1003:401.2044 10713Wrcl D CM or COi ISTR JMO1rd
J
(This. section need not be completed if the permit valuation is for $100.00 or less). CONSTRUCTION F 1 �1 ni?f1-4} �?0(i x4,44
( ) I certify that in the performance of the work for which this permit is issued,
1 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' compensationprovisions of Section 3700 of the Labor
3 Code, I shall forthwith comply with those provisions.
ApplicantIle
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 ' � r "• 1:.: a ' O F',' _,y ;-••`
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees. � F>; ,: •, • • •- • �
IMPORTANT Application is hereby made to the Director of Building and SafetyF�i'
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 tocik3'TiY! �:L. OLINIRL:'�'1"i�2dk`t1a 1> �` �''li•r3t}
any permit issued as a result of this applicaton agrees to, & shall, indemnify USS PR&PiVD.1TFXS $13.011
& 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 pLVIAT111M I)OX NOW
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 1•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.
� - � �• ' �� - �.,1i �" � RECEIPT DATE J(/ BY , DATE LED INSPEC
r 30
Signature (Owner/Agent) Dater i
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.
e 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
I
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final 717,11a 11,65
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
Law Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Wily Notice (Perm)