0307-085 (BLCK)r
--LICENSED CONTRACTOR DECLARATION
^I hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
C14 W Professionals Code, and my License is in full force and effect.
O =) ch License # Lic. Class Exp. Date
d rn f :384 k3 Ekr�)0104
LU
K
t �, gig•,- 1
ZCIDO /Date tl a i , �S`ignature of Contractor �" g°"' ` ✓ �`
J UCID
OWNER -BUILDER DECLARATION
W W r- I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ a License Law for the following reason:
Z_ ( ) 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 to construct the project (Sec. 7044, Business & Professionals
Code).
C0 ( ) I am e.eynpt tinder.:gection _ ,_f3&P.0 forahis•TeaS`d0_. .
N LO
Date --_ .p_ ignature of Owner S iA
O � ; � .. G�
d Q WORKER'S COMPENSATION DECLARATION
C:) Z I hereby affirm under penalty of perjury one of the following declarations:
O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W �= compensation, as provided for by Section 3700 of the Labor Code, for the
mJ Q performance of the work for which this permit is issued.
Q U (NJ I have and will maintain workers' compensation insurance, as required by
O tJ Q Section 3700 of the Labor Code, for the performance of the work for which this
Il L Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier U`l'.A'JEP;1340 Policy No. 0``'0229-0029'7,=7-6003
CIS Z
C3
J
(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 prQyisions;of,Section-3700, of the Labor
Code s.lstiall witl comply with those prvlslo_Qsr+ t."'o
Date -
Warning:
/ Applicant ti' '�
�f 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
3 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 propterty,for inspection purposes. r
".,
Signature (Owner/Agent) +"° k w ' ! "' M Date v ¢1 0 )
BUILDING PERMIT PERM'T00
DATE VALUATION &4j69-.,10 LOT TRACT
JOB SITE
ADDRESS '52 °025 ftWENWA D=.
APN "
OWNER
CONTRACTOR / DESIGNER / EN (NEER
X.C. IYEV ;LCA MEN*)!
R.C. Dl✓�fli1103MM,
8q-145 VISTAf:ikANDE,
80—a45 VSFFA.Gi4.PNDE
L&t1Ii wrA CA41223
.A.QT 1 p. CA 92252
(760)576.0325 aBIR
USE OF PERMIT
SIL .l'. 3f,.L1` J3.r 51 l"^Y of [,A Dei y�'• �V�71�7Y,� w�yt, G S'i•:v l.i1A 1'll 74 J .
('!,ARDDATEIYA LY, at's,'iMBO 1° KXTANI111t:, 31 W9i.OUGH,'r F.SiON
PAIT111JA A.L ,, C AT "' S i'AAND.fSSrUD
5 P7. "YA .• . i 2, Ott 1A
6 i�7'. �1►�..1� ti.�.Ofl LR'
1
HUM. & E D, CCIITC�WVi ONO— Irk-`"I'ION
4,6911
3PER.Mrf I XIX, R%VAIN1i.Ii'Y
CONISTRU);.`MA!0111 101-000=41E- 0 T7210
ISIT18.1�3 ..L COAU11RU•E"' habT TIVarcWYZFI
x,((10
s.IRM PRE41ilFSOcV
•sYca:rAL PF.Rt,,t!Tf FET#s DUE HOW
RECEIPT
DATE /
BY / !
DATE 151YALED
INSPECTO
PM
INSPECTION RECORD
OPERATION
DATE
I 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 Wali Firewall
Exterior Lath
Drywall - Int. Lath
t
Final =
Final
BLOCKWALL APPROVALS
_
� POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
d
Equipment Location
Underground Electric
11/� I'✓L ,,� /a (
�O .
Underground Pibg. 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
OX 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:
;air
„
I