9912-105 (BLCK)c r LICENSED CONTRACTOR DECLARATION' •a•,
I hereby affirm under penalty ofperjury that I am licensed under provisions of .
ty�✓ Chapter,9 (commencing with Section 7000) of Division 3 of.the Business and
Professionals Code, and my License is in full force and effect.
CV) Lice1 se # ?, ,6 ` 6LClass, Exp. Date
LO
` 519�C:iti.� _ a .i?i - a , 03/3.1/22U1
Date_ r7, ��S nature of Contractor
o !CID OWNER -BUILDER DECLARATION f
I hereby affirm under penalty of perjury that) am exempt from the Contractor's
License Lawfor 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 isnot intended or offered for
sale (Sec. 7044, Business & Professionals Code).
( )' I, as owner of the. property,, am exclusively contracting with licensed r'
contractors to construct the project (Sec..7044, Business & Professionals
a • Code).' '
,I am exempt under Section B&PC. for this reason
LO
C\1 Date _ Signature of Owner,
rn
Q WORKER'S COMPENSATION DECLARATION
z I 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' .
compensation, as provided for,bjiSection 3700 of the Labor Code, for. -the
J perfo�fmance of the work for,which this'permitis issued.
Q
(), rel I have and will maintain workers' compensation insurance, as required by
Sectio 3700 of the Labor Code, for the performance of the work for which this
Z permit is issued..My workers' •compensation insurance carrier '& policy no. are:
Carrier 1.• Policy No.
Z), - !'t1T;N,,/1'Ms.I'/�a'�'A i1\ rki�. CT)�CA d;. Al4..��t1(•.
i'.l\4JrVL4/14 F � di.1 U: • ,t C4J `• .3.1' .J,!M� :.1}13 !:a
J (This section need not be completed if the -permit valuation is for $100.00'or)ess).
() I certify that in the performance of the work for which this permit is issued,
.l 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 wor�Cers'compensation provisions of Section 3700 of the Labor
Code, I sh I forthwi h -comply wlth•those,provisions.
Dater "7 (. ►Applicant '1l t
Warning: Failure to secure Work ers'•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 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
o & 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.
O= 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-re.prese,tatives.of this City to enter upon
• the above-mentioned.property for, inspection urposes f l
tz-
Signature (Owner/Agent) `�--��`''Q�� Date +��A,
`g.F,f is i , ' .tl. •'�� j�-�.. F-� � - -. t
BUILDING PERMIT. PERMIT# • ;
`.
DATE n /� VALUATION LOT TRACT
96
JOB SITE + ]7AFN_7ADDRESS-
,
OWNER
CONTRACTOR / DESIGNER / ENGINEER 'k
yy�� �/ sL p
!'t �i`� . J.�i 1. c;' �'�"i� '� r Ta�'Y'
+.,« - c s. '„ a•.�. c.: r• -
/'' A•t. A T1 A V' 1} f''�1NIVJ A'A4'y
t-,;, W C i�
6 a 70 4'sMUU -ii-M .t; fila DID v E, SUITE 203
1370 SRs3OKi-i.C31.,i.c:r W DRIVE' SUI.,U r 108.1 '
S1'\SVT& ANA CA. 92705
SANTA. A.A CA. 92705
d79'4174i••41Yi Ir' 4414 ?. '
,USE OF PERMIT
10 LIP'. 6 tTf? A f 7L.3'., 5' (11) uiit'2D N WAIL - uRC-0 S i AMDARD
6 ii', WALL
1 5 17T. WALL 4:7:00 Lf''
r
. T'6?^!'3'(.8'. 'SDi•Y\,6�"y('ff.�i�Y 'a�i!,{'tP\'AT6}'Y k37'fI".arY•.7R111.1
.in.Y.kd12tA!'A.tl.V.6J'b..enY.l,JL','A,MkBLv,Y.►;r,S0.11.-3..14t•i`6
9 Qe4 4a,
"- A),.Svti.<Iad:
11FIAM-Yr VEitr slu-NIiMAM
r
CiONS'1'RUCT1t0NA-FE i 101-000-418-000
`i fid-"Fi;7'i'_A1, t S iN ref F_<:! f(,l'tPN �1 N'F) t -'(,AW C*E)R('
t5d
} �+�
• .i.a.L � a �L.'A\ia'6 J 6A.T✓ 1�.{�.Lf,T
(t'�0
'oaf¢ til r .
FOXIIAL PEIRIMIT VMS DUE NOW
}
RECEIPT
DATE
BY{ \)\
D 1 LE �/J��
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forrrd,- & 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
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 -/--vim?
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
COMMENTS:
'
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp, Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)