9911-039 (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 (#{n�'/� { yyLiic. Class Exp. Date 3012(k
if �l /�✓ . ,.
�Dafe � 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:
( ) 1, 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).
( ) ,1, as owner of the.- property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
O 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 followingdeclarations`.
O I have and will maintain a. certificate of consent to self -insure for.worke'rs'
compensation, as -.provided for by Section 3700 of the Labor. Code,: for the
performance of the work`for.which this permit is issued.
(jJ_ I have and will maintain workers' compensation , 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. Policy No.
i i�f,`a: C`Uf°' !�►�`"t .11.
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(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 that if I should become
subject to the workers' compensation provisions of Section 37g0''6f the Labor
Code, I shall'forthwith comply with, those provisions
Date: ; Z 02 AF 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 condition's. 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 applicator 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 authorize representatives of this City to enter upon
the above-mentioned property for inspectign purposes.
'Signature (Owner/Agent) /�. Date.
BUILDING PERMIT PERMIT#
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DATE VALUATION .i'i�;� LOT tq
, TRACT, , 2530 3
JOB SITE ADDRESS ",J1VC••520..�P�'�irLi a"KA1.�.TIO�:CVE
APN 769-050-003
OWNER
CONTRACTOR /DESIGNER /�ENGINEER
R r peNiE& L"J..�
}11r INYkA C
LA QUINTA CA 9ZZJ�3
PROFNIX AZ 8503%4
(6q�,12574656 MA. 4-990
ti
USE OF PERMIT
81N•OIJ3.Ft3,XNA DIYVELLE1 i'u
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OR, P(XAL PLAN CWCK P01;Vt7014 OF FIMS, d XIC OD 755S.170k' mUtd 1'ing
ISSUANCE0)r' ;SAMIF 'C'y p
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0ARAGPJCAR1,X)RT 498.'00 8F
PFAIM-111 FEE 84A, 11MARY
COAst;'Tt3.Ef'MC:NFIFE 401-000.418.01M 31,042.00'—'F
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AH.'l.' IN € UBLIC PLJACES- Rks'SIO 70'1-006-2554WO'
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1XISS PRE -PAID FF ES
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RECEIPT
DATE
I.///I k
BY
P 1 X
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
-L=�—
s� �
Return Air
Steel
Combustion Air
Roof Deck
��G�
Exhaust Fans
O.K. to Wrap
Z - Z
F.A.U.
- G_G
Framing
oe?- L
Compressor
Insulation
a-
Vents
Fireplace P.L.
Grills
Fireplace T.Q.
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 Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
�;� �-
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shqwer Pans
O.K. for Finish Plaster
Sewer Lateral
l� BC'i
Pool Cover
Sewer Connection I
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
"� 5
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
FinalGC/
Utility Notice (Perm)
- O- 4i