9903-163 (BLCK)LICENSED CONTRACTOR DECLARATION
1'hereby affirm uncip . r.per)aIty of perjury that I am licensed under provisions of
.Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Pr&6ssionalsCodie, and'my License is in full force and effect.
t .License # Lic. Class Exp. Date J
&31/00
V.,
.14? 0�7 Signature of Contract -4
472
OWNER -BUILDER DECLARATION.
I h�ereby affirm under penalty of perjury that I am exempt from the Contractor's
License' Law for the following reason:
ownei`bf 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 (Se6.- 7044, Busines's & Professionals. Code).
1, aCs',oWher of the property, am exclusively contracting with. licensed,
Onteacto.'irs, to construct the project (Sec. 7044,- Business & Professionals
A
Code):.
exempt under Section B&P.C. for this reason,
Date,.. -• _Signature of Owner
WORKER'S COMPENSATION DECLARATION
1',hereby :affirm under ,penalty of.perjury one of the followirig declaraitiong:
'have and.will,.maintain a certificate of consent to self -insure for workers'..
compensation,..as- pr6Vided'for. by Section 3700 of the Labor Code, for the
performance of the'w6rk for which this permit is issued.
I have*and'will maintain workers' compensation insurance, as required by
Y
Settion 3700 of the Labor Code, for the performance of the work for which this
permit is is compensation -insurance 4 & policy no. a
, - Sued. My workers' on -insurance carrier re:
Carrier Policy No.'
S 117FOND .00 13761
TA 4V-99.
(This section heed not be completed if the permit valuation is for. * $100.00 or less).
. I(% ).J'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 become
su6jedio the workers'., compensation provisions of Section 3700 of the Labor
Code,-! I shall forthwith'co'r�ply With those provisions.
Yaie:4ZA, Applicant 19—L, =4�--Cl
Warning:. Failure to secure Workers' Comp6nsation coverage -is unlawful and
Shall subject an-employerto criminal penalties and civil fines up to $100,000,'in
addition to the cost of compensation, damages as provided for in.Section 3706
of t,he,Laboi Code, interest and attorney's fees..
imponTANT Applluatlui I Is I iui.eby made to 1hL% Dieect6r of Building and Safety
subject to the,, conditi66s.iand 'restrictions set forth 'on' 'his
app, ication. -
,,-A.�n-
Each persoup6ni whose behalf this application is made & each person at
whok 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
&'h61d' harmless less 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
��ork is •nof Commenced within 11 180 - days from date of issuance of. such
permit; or cessation of -work f6r 180 days will subject permit to cancellation.
I,certify that I have read this.�pplication and state that the above information is
co.rrectf', '-agree to comply with all City, and State laws relating to the building
60n'"ction, and hereby authorize representatives of this City to enter upon
th'e above -mentioned property for, inspecti6n purposes.
Signature (Owner/Agerit) d .11�5� �5; Date -->..11- /o
e J
BUILDING PERMIT PERMIT# . %
DATE VALUATION LOT TRACT
JOB SITE r
APN
ADDRESS 47-576 VITA INIONI ESSA
OWNER
CONTRACTOR/DESIGNER/ENGINEER
N43CHA .01
13L DEII PN COXV'RUCTION
MI4HA,0,181ERGIN CONSIX"LIMION
77M9 SKAVAI;LD WXY
'72929 SKYWARD WAY
PALM DESERT CA 97260
PALM DES131t1 CA, 92264)
C76 )862 9058 061,0 4277
USE OF PERMIT
OFARAL MADYNG
NO L.F., 51000)04 WMLi .6 LIS,. 4`.GARMJX WLL, OffY
ANDARU',k.
4P'T, WALL f.0)0 LF
PKISTININMID C0.81 OF CONSTRUCT=
PE RM ff 0101', 8 M"' N"
C 0?4.TMUCTk0N FEE 101�Mk.418-000 $63.00
k
1,23SS PRE.*41AID FEES
$0.00
NOW
f0TAL PERINUT.F0, 3 DUE',
RECEIPTY 7-1 By4-)J DATE FINALED INSPECTOR'
�e
q 1 ' " 1 ;- ?; I-
t .
,2 y 1
V I -
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
r 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 & Controls '
Party Wall Insulation
Condensate Lines
Party Wail Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings – -
Main Drain
Bond Beam 3 /—
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final ziGas
Piping
PLUMBING AP ROVALS
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.1.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)