9912-169 (BLCK)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
3R 1984 C29 -
ate ~! ` Signature of Contractor
-.
'OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for 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 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).
() I am exempt Under Section B&P.C. for this reason •
Date Signature of Owner
BUILDING PERMIT PERMIT J!
DATE wrninVALUATION LOT TRACT.
JOB SITE
ADDRESS�r66�,�:tt1�>ra /lri9l l.fi°_ APN
OWNER CONTRACTOR/DESIGNER/ENGINEER
��ildAAt((''1'.t14)1'E?i`fd'f nt+V, h f A �r"'i�r3JY
dF•U;)•► T*.L./IZIU hP N.
x,2,.82(1 L XfROBE LAME 662 V i.`" 'E� (i}"s),, i..?'�G 1 Ce'.;� N
LA (XRNTA, CA 92,253 PALM 0kS'R1kT cit. 92X55
(7tft37-0289 t:18(„{" 5503
USE OF PERMIT
11.2 L.('., V dA%2DIN W A,II, ORG'f` k ANDARrr:1(}s'fAIr4 G WA, L,3-
L.Y. K 2; heti Wt. 0 l.,.;~- tt R'. C:i`f' Y S'sl'.AN7'.'oAm)
WORKER'S COMPENSATION DECLARATION
'
I hereby affirm under penalty of perjury one of the following declarations`
O I have and will maintain a certificate of consent to self -insure for workers
6 F'A. WALL L a 12•f?a3 fi'r
compensation, as provided for by Section 3700 of the Labor Code, for the
5 11+, WALL 40.00 LF
performance of the work for which this permit is issued.4:4r1%
WALL, Y
( 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
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permit.is issued. My workers' compensation insurance carrier & policy no. are:
Carrier, 1 Policy No. n L it nu E tW t� y�r ry rye gyp, f�lrr mroact
ttr ISTIii2kR7iAN)(�IVAr Oi��1r!✓i•:gS�i�,c9.L'lC'i?RV.a4'v
(This section need not be completed if the permit valuation is for $.100.00 or less). #'URNO T ' 'X ,SSVMA4A.'rrkV
(.) I certify that in the performance of the work for which.this permit is issued, CONS11RUCT1014 F"HP, t 1,.k3Si{?-Vii$--() 3(► $ts9.
I shall not employ any person in any mannerso as to become subject to the
workers' compensation laws of California, and agree that if I should become
slect to the workers' compensation provisions ofSectio'r.1 3700 of, the Labor
Code I shall forthwith comply with those pro Isiolf(s� /
Applicant "`�..7/it°..�l z ,iii
7:1--vto�p�
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 providedfor 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 l 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
const`tction, and hereby authorize representatives of thi City to'enter upon
the above-mentioned property for inspectioyur oses.
Sig ature (Owner/Agent) a Date/ RECEIPT
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LESS "ME-P.A.MPRES 40.00
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DATE I BY/ / ( DATE FINALED I INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS_
MECHANICAL APPROVALS
Set Backs /J
Forms & Footings �1 ` �� S (
'l
Underground Ducts
Ducts
Slab Grade
o
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 6 /.2- S.Og
Electric Bond
Footings
Main Drain
Bond Beam y _ Q Z _
Approval to Cover
O-rX>
Equipment Location
Underground Electric
_ g, cw
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
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection 1-7-47o
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
G.F.I.
Smoke Detectors
Temp. Use of Power
Final.
Utility Notice (Perm)