0002-025 (SFD)LICENSED CONTRACTOR DECLARATION'
I, here . by affirm under penalty of perjury.thal I am _Iicenseid under provisions of
'-Ciia`pfe� 9 (6ommencing with. Section 7000) of Division 3 of the Business and
Profession als..Codel,, and.my License is -in full force and effect.
Cicense# �'.uc. ans: ExI5.'Date.
,
V rfllf20i
o:
Date"I/ 'Signature,6f Contracto
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, Bus . ines . s & Professionals Code).r'
vol;
as '.o"6r of she 1properh
y, am exclusively contract! ng,,4rth licensed
contractors to:.coristru6>-th1eZpfoject (Sec.,7044, 'Business 90rofessionals
codeY
An
O 1 -am eexemptunder ect.i;. ") .<l B&P,:d. for this reason
Date (.Signature wner,4<
,,nature of, 0
WORKEIR'S'COMPEN,SIATION,DECL.ARATION
,�
I here*by affirm 'L inde(O' qna"yofdperjury One, of the following.AdeclaratiOns:
O I have,Eind Will mi a -certificate of consent to. self-in'sepre for workers'
• compensatiori,',- as't"p'r'ovi'd46'd/for'rl-'b)I Section 3%6. of .the La6( rrCode, for the
work for , which t' "o, </
performance 6f tli6 his perrhit.islissued.,'
I have and will maintain workers"co'mpensation insurance, as required by
Section 3700 of the Labor Code, for thd performance of the work for which this
permit. is issued., My"w61rkers compensation-in'surance carrier &'policy no. are:
Cai�irier Policy No: ()4&.,9007339 -
-
(This'section need' not be completed if the. permit valuation is for $100.00 or less);
O I certify that:,in the performance of the work for which-thi' s permit is issued,
1,shall'.not employ any person in any manner so as to become subject to the
workers' compensation laws of California;-a-na ai-g�n that if I should become
subject to the workers''compensation provisions of Secti6ri 3700 of the Labor
19 ns.
Dat- Applicantter _A I -)
Code, shall . -forthwith comply with those pr vis
Warninig Failure to secure workers' C . ompensation coverage is/unlaWful 'and
shall subject an employerto criminal 'penalties and civil fin6s up to $100,000, in.
addition to the cost of compehsation, damages as provided for in- Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the-Direct6r of EPuiloing and Safety
for a permit subject- to conditions and
restrictions-get forth on his
application.
1. Each person upon w66se, behalf this application is made ,,& each person at
whose request and for whose be • efit, work is performed underor pursuant to
any permit issued -as a resultprthis'applicatoh agrees to, &shall, indemnify
& hold harmless the " City-oj, 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 oViisuance of such
permit, or cessation of Work for 180 days will subject permit to cancellation.
I certify that I have r4ad,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 h6re6y authorize representatives of this City to.enter Upon
N
the above-m6ntioned property for inspection p rposes.
"y
Signature (Owner/Agent) Date
Z.Z
PERMIT #
'BUILDING PERMIT`
DATE VALUATION LOT TRACT 293()
JOB SITE *4497 VISTAPAir OM-iiiNO
APN 40-lihmi"
ADDRESS
OWNER
CONTRACTOR DESIGNER ENGINEER
.0 _JChAt7'I1T,r
-.1FARUX", 0%kZ
X) BO�X, 1 IM
79 _ 05 RANIC114. LJIL CIPINII,
'A DR.
Liv (� U I 141.1-A CA W253
, %
LA QUINTA. CA922-
796 C-81,0 �
6 -71-1941
"'A 0,4
USE OF PERMIT
SINOL I'L 560 -
E: PAMA Y bWSUL
SAME, PLANTWE.
-11 T111"a. i Cr 4 7A- 60 S'
S 2.6 Sq� .
41
M.0104 SF
C. STIAUkTIED C015T 0-F C0WsrrRUCV.GN
PEARMIT FE E, SUMMAX17
CON'TrRUCTION FEN 101-000441.8-000
RUVO (711", X; - E EE
Ec F )01 .49 18
NO" *4T 'AL n4;r i 0 1 _^VW -42 I -OW
IWAXR, M
$244,71
PLUNOANG VEE 101_000'. 9_000 $205.00
-STRONGY TMOMN 4"0+- - 0.81D 10j,000-YI-Off) $35.14
0 1 -001a,.�73,000 $20;00
fifiv-L. LOPER fWACr Fr. I,
ARTJN PLIBLIC'PLACEs M.W 701-PW2�.5-000
S RTR AND RL CYFCK UB-'! ",.-AL ON CXTC117164'
PEW)F11.1issR",
ov
10f All S 'I WE
RECEIPT
DATE
BY,",
?ATE FINALED INSPECTOR
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
Z I
F.A.U.
Framing
�,
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall FirewallJ.
Exterior Lath
1
-_
Drywall - Int. Lath
Final f��
BLOCKW LL APPROVALS
Final
steel
POO SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
sZ(p—pa
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
Final
Utility Notice (Gas) 7
ELECTRIC L APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors Ll
Temp. Use of Power
Final
Utility Notice (Perm)
C MMENTS: