0009-169 (BLCK)'LICENSED CONTRACTOR DECLARATION
1 -hereby affirm under penalty of perjury that I am lic'qnsed under provisions of
t4pter 9 (commencing with Section 7000) of Division 3 of I the Business and
Professionals_ Code, and my License is in full force and effect.
License #Lic. Class Exp. Date
.331412 C53 .41
R.,
-7 5"-oe-) -Iv I
L/Date Sinature of Contia-to.
OWNER -BUILDER DECLARATION
I hereby aff�ir%, under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) '- 1, as owner of the 'property, or my'employees with wages as their sde
comp6nsation, Will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
1, as 6vner'of the prop6riy,.am exclusively' contracting with licensefi
contractors to construct the project (Sec. 7044, Business & Professionals %%
Code).
O I am exempt under Section B&P.C. for this reason -
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under p4n'alty of perjury one of the following declarations:
( ) I have and will maintain a certificate of consent to §elf-insUre for workers'
compensation, as provided for*,by Section 3700 of the � Labor Cdde,, for the
perf&—mance of the work for which this permit is issued:
will maintain workers' compensation insurance, as requiredby
Sec ' tion 3700 of the Labor Code, for the performance of the work for which this
permit is issued. My workers' compensation insurance carrier 8, policy no. are:
QuTierPolicy No.
STATE FUND229 D0l2'%�S
(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 be6ome.
compensation 'subject to the workers' cprovisions' ofSectioi:3700 of the Labor
. . , r on .11
"Code, Ushall forthwith comply withih7e prbyLs�i o-ris4' v.
Date: 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 Directorof Building uilding and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1: Eaeh 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 applicafon agrees to, & shall, indemnify
A 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 irorn date!6f 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 tfi6 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 property for• inspection purposes
Signature (Owner/Ag e16, 71.1 'Date--
-BUILDING PERMIT
PERMIT#
L
DATE VALUATION LOT
TRACT.
09/25= $939.00
JOB SITE
APN
ADDRESS V-94.1 WAFLORMCE
OWNER
CONTRACTOR DESIGNER EN (NEER
ALT)KRYMCOUSTRUCHOP
78 -_74,S_ \((,Q_
74-360 VaNWO RD
PALM MEWf CA, 92260
2-5 3
(760)Ka 3-3293-. CBW,
_5302,
USE OF PERMIT
GMOEMAL jsuama-m
10 LF X 6, 20 Ur X 5- &.16 -LF X 4' RETAWINO WALL AS PFIR.
M31HERRED PL"_ S.
6 n. Wu - ,L
10.00 LF
5 FT. WALL
20.00 LF
4 rt WALL
16.00 LF
19NMAWD COST OF CONSTRUM7014
Yu
CONSMUCT)ON FXX 101-000.418-000
SUB -TIINALCONEri Ru (n iom Aw T) Pi -Ax cwjnc
$21.00
-S
r PRE PAW YM
$0t 00
TY-CALPMUM JOEIES DUEROW
I
RECEIPT
DATE^7
L
TE, FINALE
INSPECTOR
- cI
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
0. K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 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 Z
Main Drain
Bond Beam �Mx
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING/ A PROVALS
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
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)