9911-033 (SFD): LICENSED` CONTRACTOR DECLARATION
Thereby affirm under penalty of perjury that am licensed under proyisions.of
Chapter 9'.(cgmmencing 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
6906545 J3.
ate ! •/ r�`1 �'� d,"Signature of Contractor ! f
OWNER -BUILDER' DECLARATION
I hereby;affirm Linder penalty of perjury.that l 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 is not intended or'offered for
sale (Sec. 7044;'Business & Professionals Code).
(:) I, as owner ,of the:.property, `am exclusively contracting with licensed
contractors fo . `construct the project- (Sec. 7044, Business '& Professionals
Code):
O I am exempf under Section : B&PC.'for'this reason
Date Signature• •of Owner.
WORKER'S COMPENSATION DECLARATION
I heeeby.affirm, under penalty of •perjury one .of'the following declarations:
O I have and will maintain'a.certificate of consent to self -insure .for workers'
compensation," as.:provided'for b Section 3700 of the Labor .Code,. for the
performance of.the work,for which this permit'is.issued.
( 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.'
(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 3700 of the Labor
Code, I, shat -forthwith comply with those pro��uulsl? "
ate:•.. / v'I ATA" Applicant 1 "is-io�1
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to, criminal penalties,anl' civil fines up•to.$100,000, .n
addition to the cost of compensation, damages as provided for imsection 3706
of the Labor Code, interest and attorney's fees.. "
IMPORTANT Application is hereby made to the Director of Building.and Safety
for 'a permit subject to the conditions and restrictions set forth. on..his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose.benefit work is -performed under or pursuant to
any permit issued as a: result of this applicaton agrees to, '& shall, indemnify
•&':.hold harmless the City'of La Quinta, its officers, agents and employees.
2. Any,permit issued,as a result 'of this application becomes.null and void.if
work is not commenced within 180 days. from date. of . issuance 'of "such
permit, or cessation of work for 180 days. will subject permit to cancellation:
I certify that I have read this application and state that the above information is
correct. I agree to comply with all. City, and State laws relating to the building
construction, `and hereby authorize representatives of this City to enter upon
the above-mentioned 'property for inspection pur,p'oses
nature (Owner/Agent) " Date
PERMIT #
BUILDING PERMIT.
DATE / A6/f/
/ `� VALUATIONa�,s_��I LOT' f TRACT [y.�
/ s1
JOB SITE
ADDRESS 54-U 5 }SPVC`.t� ASS HILL DW VF, 7N
OWNyE�R
CONTRACTOR/ DESIGNER /�ENGINEER
pp±r LLC
LAS .i ',N0h 4i.,S .LLC
,.f tic� i� � e+ �7� i M'L:�i l�u'p ii°F w.. �.�• .¢ -
3.1
�%`'�tf:.T
i.A 5;8:t�Ft!'A. ;( ,?254s11
:� AZ i•
�cti? rZ�i p:65 C YfA • 4990
USE OF PERMIT-
1�`d.k�.ati.k�9l.f,�l''.L1�b�rLNtf
1
M P(IXI)E
clii•vroM Z6IQ a SF`
.
OARAf3p:Jt';i1I'tPO+s>iT 402zM5F
CONS;T
2 141 A.
;.36i1-0DO-•rli8�?(".4= tars
KAN C'Fi>f?l' FW, I.. �'��7
61050)''
%.L:#�.C:.�aiCr�,t: i��;, • '��i?i••i�`ii i?••�I:��i •G+C3tD �1.$:! •
..
9�i Ut IT�lIB.Ei i.tFt-� 1 ;ii -Ot ii $180;
i
�t�rizt•.>'at0 (�r,3�a'iC�nT:�±�a Rx;�ai� si�,s l�)t1 �;�;� t14P!'! . • ���! 4f�:
+
��tlt.)SF�f.T b lf..a;! �JttQ••-ta � f1JU: $�J.cFtt
.:;� : `"-� .
WMOfi':.?#C .C,4i+T-ACT AM, i V.,901 00
t 7
ti'I' fAi 4rTJ?LI� IAI.�Cfsi0(lL�GI
• r�.
awl. , . ,; f
'J.�r
LESS- aI"",E P fl) PE.E`.,.S.
r �. $0.0
.'rarALA PERMIT (l+E.Cgi:alip,NOW'
S4,57826
RECEIPT
DATE
BY i
DATE FI ALED
INSPECTOR,/
/ f 1. "
.12,
K/ '
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
-
Ducts
Slab Grade
ll/C
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
GcJ
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Firiplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
.ICJ
Final
Final
_
S_l� �
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
Waste Lines
Gas Test
Electric Final
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
�.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) - -