9908-076 (RR)LICENSED CONTRACTOR DECLARATION
,-I'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. Date
235717 C_ I -C) 01/31/20
C . /, /_
�Date Signature of Contra t r — ;&
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 properfy, 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
( ) 1, as owner of the property, am exclusively contracting with licensed
contractors to constrAt the project (Sec. 7044, Business & Professionals
Code). I
( ) 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:
Cartier Policy No.
STAM' F UIN D 14 24 1.1110 - f 1"Z
(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 notiemploy any person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if I should become
subOct to the workers' compensation provisions of Section 3700,99the Labor
Co'de, I shall forthwith comply with those"" rovisil
IV -) - I � — r7ZZ'l,
%,Date: ? I ' 9" Applicant—
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 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
constructi6n, and hereby authorize representatives of this City to enter upon
the abo"ve- mentioned property for inspeptioZnurpose
-n,
A , — _?* .6,
Signature (Owner/Agent) Date
PERMIT#
BUILDING PERMIT M84076
DATE in
ion"VALLIATION LOT TRACT
S3,97.
JOB SITE APN
ADDRESS 77-800 CALLE ENSENADA 71,13-271-024
OWNER CONTRACTOR / DESIGNER ENGINEER
CA R t'.0"S `,s' kt. ICU 01 V I A VV 0 -0 A -TIrl. f0%.*C_1'.0Jm3t1%F11__#1
'17Wj CALLE ENSR4ADA. 3462 LA C'AMPANA AA V
lik QU191'A CA W253 PALM SPRINGS CA 142264'
(7014 1 & _W7 CRIA 4293
USE OF PERMIT
(A."NERM, WiLbi-No
RG-W)OF Wi CLASS W UU111,1- UP kl:)O� ING
R1177 -IMP
1 9_5 W
.% 1.1.4 . is
PCHMIT FET,
XWOX)f,"VEE 1014YW-418-000
SM
-1K)TAI,("0NS'YVkW'Y10N ANOPTANCIMCK (10
L � �V, T I ME- V,*0 D E E S (110
TMAL d' RMIT VEYN DUE NOW &UM10
RECEIPT I DATE I BY; - I DATE FINALED IINSPECTOR
INSPECTION RECORD
OPERATION DATE INSPECTOR
BUILDING APPROVALS
Set Backs
Forms 9 Footings
Slab Grade
Steel
Roof Deck IT
OX to Wrap
Framing
Insulation
Fireplace P.L.
Fireplace T.0,
Party Wall insulation
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
OPERATION I DATE - I INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
ExhaustFans
F.A.U.
Compressor
Vents
Grills
Fans & Controls
Condensate Lines
Sewer Connection Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp2 Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F. L
Smoke Detectors
Temp., Use of Power
Final
Utility Notice (Perm)
Final I I
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
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp2 Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F. L
Smoke Detectors
Temp., Use of Power
Final
Utility Notice (Perm)