0206-032 (BLCK)LICENSED CONTRACTOR DECLARATION BUILDING PERMIT PERMIT#
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 DATE VALUATION LOT TRACT
C14W Professionals Code, and my License is in full force and effect. �'' ��aa�•�
c*� License # Lic. Class y Exp. Date 1
+ JOB SITE APN
LU r 4, �3 /Oz ADDRESS ;52-%5 AV.E•1`�1)A'.FJFXRF..RA .
Z' � Date SI nature of Contractor �,c� % ^+ OWNER CONTRACTOR / DESIGNER I ENGINEER
O o s ._ g ' 1��+.C:l C 7,'T.�' A) 81 Ct'��lSMUC`1YON I7.�►MI iRAM �,, C1:ON1�"dTT�MON
H OWNER -BUILDER DECLARATION
W W I hereby affirm under penalty of perjury that I am` exempt from the Contractor's2.�� i '3�i+' S�"!�'11 l 7551!'C'"" �'3�?;.1111 i 11
H aCART.. BAD C""sa 97(m CfiWaRAD CA 971508
N License Law for the following reason:
Z ( ) I, as owner of the property, or my employees with wages as their sole (760Y?304431 IC'SIA 1955
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 C#M4MAJ1MUNt G
contractors to construct the project (Sec. 7044, Business & Professionals
Code). 40 "'LF. 6' 0At.RDE 1 WALI, W Lf4- GARD.Z 4 NVA,;.:� -sS 1L.1:. 32°
CY)() I am exempt under Section B&P.C. for this reason 0ARDEN WA14, 214 F 246 0ARDIM W'AIJ, AM, (NIT' STANDARD
O N Date Signature of Owner
rn
d Q WORKER'S COMPENSATION DECLARATION
p Q Z I hereby affirm under penalty of perjury one of the following declarations: ;trl��if 4
Lo .00 LF
1-— O () 1 have and will maintain a certificate of consent to self -insure for workers' 6 FT 'WA1 L 40.00 F {P
X W �= compensation, as provided for by Section 3700 of the Labor Code, for the
O � Q performance of the work for which this permit is issued.
CD Q U I 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 � Z permit is issued. My workers' compensation insurance carrier & policy no. are:.
Carver 81'f1TF,` FUND Policy No. 112390 9s.�ib?i'.Ana), con or S`-'ons'F.FslCgallm-4 f,ig�tB �iD
Q (This section need not be completed if the permit valuation is for $100.00 or less). CONSTRUCTION FETZ 1'01.0000-#1 8.000 $29.00
J () I certify that in the performance of the work for which this.permit is issued, '
1 shall not employ any person in any manner so as to beco'measubject to the
workers' compensation laws of California, and agree that{if I should become _
3 subject to the i/orkers' compensation provisions of Section 3700 of the Labor
! Code, Itslhall forthwith comply with thosprovisions., ✓�
Date: 4,1 i tl/A- Applicant 1� 00 C Lam? i r
Warning: Failure to secure Workers' Corrtpensation coverage _is unlawful and O `
shall subject an employer to criminal peas ties and civil fines p to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706 n
of the Labor Code, interest and attorney's fees. JUN
IMPORTANT Application is hereby made to the Director of Building and Safety CITYQF 1(
for a permit subject to the conditions and restrictions set forth on his F CDQE� '
application.
1. Each person upon whose behalf this application is made & each person ati*�ii Aid. 4:'i):d"fi3C:'�1t1F �lif ►�C: X79 0C
whose request and for whose benefit work is performed under or pursuant to LESS, �� �U Oi1
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 TaYAL f ERMMYI3Z&JAIR,[ OW &;49,00
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 representatiiue�of this City to enter upon
the above-mentioned property for inspection'purposes. %
, %� RECEIPT DATE BY D FINALED INSPECTOR
f' Signature (Owner/Agent) 24 W ' ` ( Date" �� t7" ��
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 Wali Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
_ -4L _
Electric Bond
Footings
.,� 1�
Main Drain
Bond Beam
_
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
. Z y �� `
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
Seaver 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
Loa Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Penn)
COMMENTS: