9910-143 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am, licensed under,provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the. Business and
Professionals Code, and my License.is.in full force and effect.
License #' Lic. Class Exp. Date
Zate".
, /'g," -sig -nature of Contractor''
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for.the following reason:
as owner of the property,•or my employees with wages as their sole
compensation, will do the work, and the structure isnot 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).
() I am exempt under Section B&P.C. for this reason_
Date • Signature of Owner.
WORKER'S COMPENSATION DECLARATION
I hereby affirm, under penalty,of perjury one of the.following declarations:
() I have and will maintain a certificate of -consent to self -insure for workers'
compensation, as provided for by Section' 3700 of the Labor .Code, for the
performance of the work for which this permit. is. issued.
( )fI have and will maintain workers' compnsation insurance, as required by
Section 3700 of'the Labor Code, for the performance of the work for 'which, this
permit -'is issued. My workers''compensation insurance carrier &'policy no. are:
Carrier �P,//tp / rtC awy� /� M Policy No..
MS. S. M1••i. MP�.C'�.1Y iI.Qri 7. - f#�r�.��i✓11!)'i �t �%�JS�,
(This section need not be completed if the permit valuation is for $100.00 or less).
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
subject'to the workers' compensation provisions of -Section 37001of the Labor
Qode, i shall 'fortHwith comply with those provisions.
'pate: fJ4E:.`'"l ,r Applicant �/ ••.' �'"
Warning: Failure to secure Workers' Compensation- coverage is unlawful and
shall subject an employer to criminal penalties and civil fines.up to'$100,000" in
addition to the cost of compensation; damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT. Application is hereby made to the .Director of Building and Safety
for, a permit subject to the 'conditions and restrictions set forth on . his
application. .
1. Each person upon whose behalf this application- is made & each. person. at
whose request and for whose benefit work. is performed under or pursuant.to
any permit issued as a result of this applicaton agrees to; 4.sFiall, indemnify
& hold harmless the City of La-Quinta,'its officers, agents and employees.
2. Any permit issued as a result of.this application becomes null and void -if
work is not commenced 'Within 180,days' from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City,'and State laws relating to the building
constyetion, and hereby authorize representatives of.this City to enter upon
the bove-mentioned property for inspection -
ignature (Owner/Agent) Date .
PERMIT #
BUILDING,PERMIT•
/
DATEJ VALUATION r y r} .''LOT,' TRACT28797
Aill
hfiAw
JOB
ADDRESS 79-�a1«"s''��'<r1�YOIN..
APN 769-460-09
OWNER
CONTRACTOR / DESIGNER
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1.125 r. ��i1i+'E Sid"YD:> Iv$
£AQUINTA. CA. 42233
PHOENIX ,.AZ 8V. 34
f(wpS71,r),% C.'81A 4"9t1
USE OF PERMIT
SINGLE FAMI LY DWY, LUNG
It"U0L.79'ott;EDU1C,"i1 N ON'r'LiVI1f C'.i"itiScx I sfaFat$:143iR•. riFix, f:`3wAiVu .
aF SIVWZ� MAN TYPE
CUSTCA11 i.,GINS�';ttUMaN 1;:577,00' 3F.
t
203.00 sp
0A RAGE(CAfO.109.1' .1= 00 3F
try
VC, L, SUMMIluly
CX) N' Ti,`1tli.',"!` 0 N 5ZOi 1U[-t)i!Q 11$ tit?it $:1042.f*
PLAN VIF-0;K.lE.E $2'14 A's
&TCi•3ANIC.9, i W
�:C.:t'itZ�693wI'�6:: , . • , ••!ib$�E-•�20���. �1:59.�x,
PLMtF3tR(1;E'i'.#' 101-000-48.9-1.00
014 FF.C-�M1-1.)-{i'0p1.-4)i.i-7,41-f�)S(G�fj;
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AXF iN P1Jl311C, PLACkN - fMiSib 701-000-1554*0 3287..:14
-9J_WTt #A!, f10MMLIM_ QN AND PLYAN t;'i-6FCK
$3,9444
DFEE
RECEIPT
DATE
BY
DAT 41M ED
INSPECTOR
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
0. K. to Wrap
F.A.U.
Framing
Compressor
Insulation Z _ Gel,
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 Hacks
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final 1
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 Voftage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) C+t2