9905-311 (RER)LICENSED CONTRACTOR DECLARATION
—1 h�reby affirm under penalty of perjury that I am licensed under provisions of
Chaoter 9 (commencing with Section 7000) of Division 3 of the Business and
04 UJ Professionals Code, and my License is in full force and effect.
CV) Licen.se # Lic. Class Exp. Date
LO 053 0 3 11113 .8
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r- rl- / 15IRShElSignature of Contracto�r�t j2 -j
Z r-_ pate
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I,- I.- C) OWNER -BUILDER DECLARATION
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W LU r- I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
Z ( ) 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).
CY) I am exempt under Section —, B&P.C. for this reason
LO
C\I Date Signature of Owner
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Li < WORKER'S COMPENSATION DECLARATION
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C) 2 Z I hereby affirm under penalty of perjury one of the following declarations:
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1-2 0 1 have and will mair'Itain a certificate of consent to self -insure for workers'
X UJ compensation, as provided for by Section 3700 of the Labor Code, for the.
0 _J performance of the work for which this permit is issued.
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< I have and will maintain workers' compensation insurance, as required by
-b (-) Seciion 3700 of the Labor Code, for the performance of the work for which this
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m l-- permit is issued. My workers' compensation insurance carrier & policy no. are:
.,t Z Carrier Policy No.
M113, FUN_
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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
subj,e6t to the workers' compensation provisions of, Bet . n 3 0 the abor
q,ode, 1,pa I fort with comply it th. osp P V' 1%
4:Z(;�kpplicant .2
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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,.,d.'amages 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.
Of
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 ity to enter upon
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the abdve-me�tioned property for inspectio,,n purposes.
t.signature (Owner/Agent) 'I Date
V
PERMIT#
BUILDING PERMIT
990.5-3,11
DATE 1),V24V199VALUATION $1,2,451M) .00 LOT TRACT
JOB SITE
ADDRESS 79-795DESCANSO 1,ANIC
646-350-001
OWNER
CONTRACTOR / DESIGNER / ENGINEER
MAI MAUEVS
OLD ppk.Sp,.10�1 r'RAVISRIAIN, HIC.
78795 DESCANSO LN
41-881 BEACON HIL' STE, A-!
LA QUINTA CA 92253
PALM DESERT CA 9271.1
(760)T73-00] 9 CM -4 1847
USE OF PERMIT
PUISININ"1111 At, REMODEL
REMODEL MUSIING BIMAZOONi WFf Bi�k CH�WE WINDOW FRO
I Z 504.00 I's
UT 1-7 Th -10 N
I ST., N19 VfAEM C WMAY' or Cla'Ni I a
PERMIT F 9E, 4.516MARY
N.AN CHFICK FEE 101-000439-31b: $93.60
C0N.'KPk(TCT,*,N Ma; 101-W-4�8_-MO S!0.01)
PLUMBINO F Fr% 101-000419-000
SYRONG MOTION FEE -'RX StD 1014M-24.11-000 SL25
SLIE�401AL CONSMUC, 110N AND P1, s CH ,Ck
I EMS RRE-PAID FEIE�s
TOTAL PEMNUT IfTIESDUE NOW
RE.CEI PT
DATE
BY
DATE FINALED
INSPECTOR
l�
9 . .
INSPECTION RECORD
OPERATION
DATE -T—INSPECTOR
OPERATION
DATE __F
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 Parts
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
.Jemp. Power Pole
Underground Conduit
.RoughWiring
Lbow Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
Smoke Detectors.
Temp. Use of Power
Final
Utility Notice (Perm).
COMMENTS: