9909-222 (CP)LIICENSED CONTRACTOR DECLARATION
1 -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: Dat 00
.� . i ;S3 i 7/3i1�Ui
/,Date ,signature ofContractor10
/ 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).
( ) 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.'
( 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.
a1"AnFUND
(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 p�,rrrit is issued:
worksI shall not'employ any person in any manner so aVection subject to -the
' compensation laws of California, and agf I should become
sub)ect to the workers' Compensation provisions 3700 of the LaborC9de, I s IYJor h�1tth comply with thossePr• Ionspate: —c`t •�'Appli.
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shajl'subject'an employer to criminal penalties and civil fines up to $160,000, in
addition to the cost of compensation, damages as provided for•in Section.3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit, subject to Ahe. conditions,<and restrictions set forth on his
application.
1. Each personupon whose behalf this application is made & each person at
whose request and for'whose benefit work is performed under or pursuant.to
any permit issued as a result of this applicaton agrees to,.&. shall; indemnify
& hold harmless the City of La.Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
Lcertifyrthat I have read this application and state that the above infotion is
correEt. I agree to comply with all City, and State laws rela�t9 the building
construction, and hereby authorize representatives Doff t�s Gt to enter upon
os�sr
the above-mentioned property for inspection pur
`'Signature (Owner/Agent) Date y
BUILDING PERMIT PERMT#
DATE I wun"VALUATION l � . . LOT TRACT
JOB SITE
ADDRESS
OWNEyR�
CONTRACTOR/ DESIGNER/ ENGINEER.
1 t3ls� Y 9 � c
a l4i�d�i�HE01,11 HILLS LLC
t o
C.�-iiL" tiJ�ivN Uk s�-1.e1.'d...S.� ADZ �S PASS
t•�� ,�; :;tl�� i��' rz" s'i'p ir�o
74-72-5 JONI DROW, -RA.
ORANICE CA 9288-6
PALM, DESM CA Q1260
(760)340-903 C8L# 153
USE OF PERMIT
CCjMMOIN i.Wk A. +C) . 'SPA, ONLY—, ALAIL ii&rIAt2%i.iM`S" SKAU. RE I
1a00:..AND/Qty :SPA 19,700-00 LS
iLA.14CEW ME 14H,-�'Ffi-�39:�SA3 �1`�a-s5
�`�i1�i'!'1$.B }C"!'Jf�i1j srti�z .j (14 •[143s�-;4.4fi'-•13�1i! �2@ 3,fii9
MEC;1iAMR:"A4. rll: _ '1''trL1i, tt;�-t3"� �1 8u 4iii13 X�'i.lii3
MOMRI.C.AL. FW, POO, i4' 441-000420-000
Fi,f,1t 030NO F --- PC3t.)L 1,0143100-41.9400 STISftt
SUB—Int'PAL('10N.FDRLdC RON AAI@XPi �UhlGWRIC .
'5437 t�
LESS FRDTAID FEES
P
RECEIPT
DATE
BY�,
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPtCTOR
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 Wall Firewall
Exterior Lath
Drywall - Int. Lath
I.
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
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
d
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
00
�Ylg
-
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)
`
'i 1, t -
3 `
t = { ih , f�Yi . { J '• JhA` k�.H {..bw / k, mt A
:l
COUNTY OF RIVERSIDE HEALTH. SERVICES AGENCY
.{ DEPARTMENT, O,F ENVIRONMENTAL HEALTH
ENVIRONMENTAL H,EALTWSERVICES
SUPPLEMENTAL REPORT_ TO SAN. FORM # DATE .41
SUBJECT PERMIT NO:
ADDRESS � �'�� �1!`•
REMARKS:
IN ECTOR',O"
�. \ 1
C 0Q
A -d2
.,-
-
` } VV
it
- •�: f A �M .
;\
(F, A-
s c
`—
o CA
1 S
Dam _
DEH -SAN -,18 (Rev 2/96)
Distribution: WHITE—Office; CANARY—Owner; PINK—Office