0004-314 (BLCK)LICENSED CONTRACTOR DECLARATION
U) I hereby affirm under penalty of perjury that I am licensed under provisions of
I— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
04 W Professionals Code, and my License is in full force and effect.
=) ch License # Lic. Class Exp? Date
t-- CYLO
UJI
744091 � ) 12I3112C
oZ � Date4k . ignature of Contractor
(D j
CD OWNER -BUILDER DECLARATION '
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ a 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).
cY) () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
ON
0)d Q WORKER'S COMPENSATION DECLARATION
p IM I hereby affirm under penalty of perjury one of the following declarations:
Lo FZ 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
m_ Q ( performer ance of the work for which this permit is issued.
Q U A)'l have and will maintain workers' compensation insurance, as required by
O UQ Sec kon 3700 of the Labor Code, for the performance of the work for which this
H permilkis issued. My workers' compensation insurance carrier & policy no. are:
z Carrier', Policy No.
Ob 5 57ATE FUND 229-00-0020714
�a
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,
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree th-1 if I should become
subject to the workers' compensation=pro�jisions of Secttion 3700 of the Labor
Code, I shall forthwith comply with those pfoovisions
Date: , - 7-�,rI-Applicant
Warning: Failure to secure Workers' Compensatidn 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 State laws relating to the building
construction, and hereby autho ize representatives of this City to enter upon
the above-mentioned property/forni spection' purposes.
) Date
Signature (Owner/Agent)
BUILDING PERMIT
DATE VALUATION LOT
04faMIX S61MM
PERMIT #
0`314 TRACT
JOB SITE APN +
ADDRESS 78-'391. T+A.4f MN113Y ROCK 11M[q _ t
OWNER
0.3}i TALXWQ ROCK TLMI N
I..A QQ•i3MTA CA 1-42253
USE OF PERMIT
CWNMZAI, i;Ull,D1NC1•
CONTRACTOR/DESIGNER/ENGINEER
T VNITA DEVEWP14Wr CORP.
77899'Wn1..F
PA12d DWERT CA 92260
(760)772.2626 MR 5393
205 L. F, 6V) C ARDEN 'WALL 601. P. T(H) RETAINII~Iil WALL
ONLY -ORCO STANDARD
6 FT, WALL
4 FT. WALL
209.00 LF
60.00 Lig
EsnWATED COSI' OF CONMUC1701f
P1 xvrt'r 1 BUMMAJRY
CrONOTRUCTION F8E 101-000-418.000 M0
RECEIPT I DATE
Vl
IMS PRE-PAIDEELS
TMA L 1'ERMU" M5 DIM IVOW
DATE FINALED I INSPECTOR
$9000
$O.00
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 & Controls
Party Wall Insulation
Condensate Lines
Party Wail Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Footings
Electric Bond
Main Drain
Bond Beam S
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:
'd/ f p • v7
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)