9911-036 (SFD)L
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
v*9fsS �f'• `r. tip/�zc�i
Date Signature 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:
( ) I, 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&RCAor 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 dce'tificate of consent to self -insure for workers'
compensation, ,as'provided for by,Section, :3700 of the Labor Code, fo'r the
performance of the work for which this permit is'issued.
()have and Will maintain workers' _compensation insurance, as required by
Suction 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' Policy No.
`'A?Dti"iof ai Igo
(This section need not be completed if the permit valuation is for $100.00 or less).
() I certify thatin the performance of the work for which thi's 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 3700 of the, Labor
Code, I shall fol•tt with comply with those provisions. �•
Date:
2/'5' ��' Applicant /� •✓
Warning: Failure to'secure Workers' Compensation coverage is'unlawful and
shall subject an employer to criminal penalties, and civil fines up to $100,000, in
addition to the Cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application' is hereby made to'the Director of Building and -Safety
for a permit subject to .the, conditions and 'restrictions set forth on his
application. < ..
1: Each person. -upon whose, behalf this application.is made & each_person.at.
whose request -and for whose benefit work is performed under.or pursuant to
any permit issued as'a result of this applicaton agrees to, & shall; indemnify
& hold harmless the City of La Quinta,. its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and.void'if
work is not commenced within.180 days from date of -issuance of such
permit, or cessation of work for 180,days will,subject permit to cancellation..
I certify that I have read this application and state that the above information is �' y
correct. I agree to comply with all City, and -State laws relating to. the building
construction, and hereby authorize representative oof this City to• enter upon
the above-mentioned property for inspection purposes.
nature (Owner/Agent)�f, Date
PERMIT#
BUI;DING PERMIT
DATE VALUATION U14;0MIJ-t0. •LOT 11 2.. TRACT + ��
- JOB SITE
ADDRESS •. .7[9• 06 i�.��YrL?,�slSair�'�T�B.LL DRIVEAPIC
OWNER
CONTRACTOR/DESIGNER/ENGINEER
9'C Y41A,'i7 i P-
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F. U - i�4EI:S .[ DRIVE
taEl.QtltM `b.A 5?"253
PHOHNIX, - AZ U94
(0,1257 465 C1,# 4990
USE OF PERMIT
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97D -LOT ;'14 -PLA -a 5r3p. D39S NOT INCLUDE MOCK W6418
ISSUANCEC7V S.AM :i LAN'TA`�:E'.
Cf iS ITON_t CON.s s"r2;iJC.('Y� 1K zr- lr! C6 b srz. ,
PORIC11WATIO . 1,40,00 V r
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EST I.AHMIED COINS
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RLAN F11%
MUCFdAMCAL FMI 101-000-421-000 "• ,$;It y.QA.;
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TOTAI, PERMIT V'ri�r4' R .R3tHE.tnT��►d�
RECEIPT DATE //`� r i BY DATE FINALED INSPECTOR
r�:
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
—,L
Underground Ducts
Forms & Footings
— / —
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
_
Exhaust Fans
O.K. to Wrap
_
F.A.U.
Framing
— G r
Compressor i . G!
Insulation
G,t/
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
,2._•�
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
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX for Finish Plaster
Sewer Lateral
6
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) Gd