0205-163 (PAT)LICENSED CONTRACTOR DECLARATION _ PERMIT#
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I hereby affirm under penalty of perjury that I am licensed under provisions of BUILDING PERMIT
F— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and DATE VALUATION LOT,-� TRACT
N LU Professionals Code, and my License is in full force and effect. 1 _, k dil) `
0 License # Lic. Class A Ex Date
W d, 2�aCt484 H 3 ll xl41�® ADDRESS 39 ,'"tom .t➢�'A1�7���i�.i�;?1 IDI A' U.) JOB SITE APN 4�b44 t'P 04
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oZ r— +' Date �' ° *�' Signature of Contractor OWNER tii CONTRACTOR/DESIGNER/EN (NEER
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TRUMON
O ��' OWNER-BUILDER DEC AR TION .1JEN�gH1y Ay�yH �` �t g��y�py� �^p�d C�ayl� ��yy��' ROAD J V r 77"J ` 2 .1.O�Y.("¢.S�iid ION DEVE "I'Q0 4 iJ Y�.�C }ci �' b4 r�� , JZOAD
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ a License Law for the following reason: LAI LA CA ��� 'fl�'3d]�.1�;�1NIDPALASS (`A �t�"J6
Z( ) I, as owner of the property, or my employees with wages as their sole (211h. 31,00
compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code). USE OF PERMIT
( ) I, as owner of the property, am exclusively contracting with licensed - mT
contractors to construct the project (Sec. 7044, Business & Professionals " A'" "" �" �' vVME L'x}7Z%
1'`) ()dam exempt under Section B&P.C. for this reason 14 X 20 AJ J.'!+'Ai�°t34�) PN110 �:Sisl'14t ACLU 6`' 131a
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O N Date Signature of Owner
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Z WORKER'S COMPENSATION DECLARATION
p � 1 hereby affirm under penalty of perjury one of the following declarations:
p () 1 have and will maintain a certificate of consent to self-insure for workers'POR-��0��
X W compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
C0 Q have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
d H permit is issued. My workers' compensation insurance carrier & policy no. are:.
v ? Carrier Ae = i Policy No.ob Z) 1��N - kf►` S4i. °IT"A'ke'D ('10" OF CaJsMTRU€:°tr' O N
Q (This section need not be completed if the permit valuation is for $100.00 or less). H� A' CHA(X TITZ A01,0'00-1391- 18
J ( ) 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 becom,2,,�subject to the UC � � C'A� j�� '4�
workers' compensation laws of California n agree that %%should become S7.:10HO I-AU310N 17M - MND a0t`i�i�-�. 4144
subject to the workers' compensation gr visions of�ectio 3700 of/fthe Labor
Code, I shall forthwith comply with those proyisio s.,,-�.,
--Date: �1; : t, � r • Applicant—
Warning:
! 1
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 att w
whose request and for whose benefit work is performed under or pursuant to��-1110T A-L '��� ���� �'��tD4,: fa
any permit issued as a result of this applicaton agrees to, & shall, indemnify $&•00
& hold harmless the City of La Quinta, its officers, agents and employees. i DftAY
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2. Any permit issued as a result of this application becomes null and void if ° i r-M�1' VMS D')333;:ft6OW
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. �1'21002
I certify that I have read this application and state that the above information is
• correct. I agree to comply, Vithrall-6ity„ and State laws relating to the building CITY OFLAQUINTA
construction, and hereby/ authorize representatives of thls City to enter upon FINANCEDEPT.
,.the above-mentioned property for inspection,purposes.� % 7
1! j tJV } { !/ Date RECEIPT DATE/,,,,,&Y.I, "i'— DA E INALED~ INSPECTOR
/ l %
Signature (Owner/Agent)! •�
P "' S
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 Wall Firewall
Exterior Lath
Drywall.- Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
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
Gas Piping
Gas Test
Appliances
Final
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)
COMMENTS:
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CITY OF LA QUINTI
BUILDING & SAFETY DEPT.
APPROVED
FOR CONSTRUCTION
DATE -S ij O�-BY
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