0205-091 (RPL)f:. 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
518742 C-53 1 10131M
r
ate'-~ "% Signature of Contractor ^�f ��` � —0 ^-' --
rr ....r-• �... �.. _ 4
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
WORKER'S COMPENSATION DECLARATION
Ihereby affirm under penalty of perjury one of the following declarations:
• ( ) I have and will maintain a certificate of consent to self -insure for workers'
compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
Se(� I have and will maintain workers' compensation insurance, as required by
N'iQn 3700 of the Labor Code, for the performance of the work for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:.
Carrier nryA,ifI? FU"j-1L. Policy No.
(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 become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall/fort with comply with those provisions.
�+6ate: 4 I , 1 Applicant
Warning: Failure to secure Workers' Compensation cov 4age 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 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 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 representatives of this City to enter upon
t 61above-mentioned propertyfor inspections purposes.
Signature (Owner/Agent)—) �Y=� f f`�' 'U p Date' r,%fit
BUILDING PERMIT PERMIT#
DATEVALUATION LOT TRACT
5 - IC- 0 2..
JOB SITEAPN
ADDRESS 78-5 Y e6TMWFA
5
- —
OWNER
CONTRACTOR /DESIGNER /EN INEER'
MD
AyAERyCA YOO�L 0_01M, fRUCM314
78.525 WIN1.1XVIY,1A
73960IYUG WAY"..111
LA QU 3ITA CA 9225:3
PAi;:M;k fMIrl' CA 9225.51-15
(760,340-2568 C.`3 UI 1104
USE OF PERMIT
POOL AND/0.17 V.A.
FOOLISPA, AJ AP.Mw/bAKF1I1= SI JAkJ,L HE W P:LOLCE PR1,011.'1O
Po: 01, AINDI R SPA u"i
COM-, OF 4011CIUMUC"/:10111
PKWiT �'3 }i'EhRU�°sY
FLAM c71i.ECK "M 10'1..006.439.318 $142-10
CCRITS`i.RUCTION RUT, 101-000.419-L100 $rm.w
UISC1i.ANICAl,PEE -,-r-'.>Olj 101.0013•421 -Wo
ZL C'!.`'R[CtA, FEE �-. POOL I
PU1Mi3EHOva .11obc 101-0900-,19.000 1 $1,17,W
� .
o
i � 1 1, JR
-- - l
CITY OF LAQUINTA
{�+y- •y+yx S +�r� i .._ FI E Chi' `1r:.
i')t.M'fw��.11•95.�. r,t r., .x ... .((.r''a.a••,��99 �.A.rkitssi�:
r
�Ph?lriG.l!
$gip0
1:Y
• ..p�pr .`�iSlf
66L,ry/y✓�y• �rc�rlcL� ����•L;+ �i
• �d V till, "9:a�iR.iFLE:C .L°:f?,�,�S Sf14i.� i80W
�t'�Ff� roC1
$4fr .10
5
RECEIPT
DATE
� --10 - 0 2..
BY
: --r-
DATE FINALED
-/0 -oa
INSPECTOR
I .
INSPECTION RECORD
OPERATION
DATE I
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 Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS.,
steel
S 2 73 —
Set Backs
Electric Bond
_ Z
Footings
Main Drain
Bond Beam
Approval to Cover
-�
Equipment Location
Underground Electric
Underground Plbg. Test
Final I
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
Encapsulation
rQ Z,
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)
•
� vn vvrlvv � nw � IVIv.
'
•`
DAT�s � 03� BY ��
T
:o
.o
/
AREA MAP
Q
LIC. 51874
V
r
1qq�hl: 7fC�`t3E�tst �/�'d
ItA1E
AD YB' Z5 rI - SEIA•LL
L�C�u/dtQ C'R 4�as3
r,
9pgEE ;� _ �• 0•
LAT BLACK S.EC
OcRTY LWv`�.
UT(L" POU
Q 49CTM 9000
� HDSL �
� SK Nik&R
� DECK
T>EL.E. L92 -3M W t� F
TY EASEMENT
TYPE
@ ELEC PAWL
® WDKR-
.. Flt lfE
`t Lraff
AREA ®. DRAM
m E (HEIGHT,
m RGROLRO E1 FGG{kv�
CN
G GAS ALTER
eEri (wuac'
Mbit
aoxnE wLVE
O TER
F FL
Q HEATER
+' W URN
R£T
THERAPY
�_= MAN
PVC
GRm RAILS
P
TL`1 ff,T 1 O!�I
r�►s
CO WAD ELUC.
VOTER DEPTH
.
GATE M>LVE0
O UAN CRAM
-s AERATOR
LADDER
Po -Box 119%
PALM-DERT CA.
AHEAD TELE
m. VEDESTu
RAi�
ACMSC'�,
_ SWITCH..
® P TRAP
O .PUMP
GA6 GRILL
SEE NOTES
a
{764) 34Q 2588 :
o WMP1ACLE
--3sTU9
t� CUP AN]M
Cey