0209-229 (MISC)` r I .
-LICENSED CONTRACTOR DECLARATION
I.hereby affirm under penalty of perjury that I am licensed under provisions of
Ciapter 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
0413012(
,"Date ��� `.' Signature of Contractotn' � •"'^---�
OWNER -BUILDER DECLARATION`_,
I hereby -affirm 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 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 Jen property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
O I am exempt undeVSection , B&P.C. for this reason
Date A Signature of Owner
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'
compensation, as provided for. by Section 3700 of the Labor Code, for the
performance of the workifor which this permit is issued.
,Q4: 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
permit,is issued. My workers' compensation insurance carrier & policy no. are:.
Carrier , r,.115URTYMUTi3.Al l?: Policy No. Y,#A162D00Mb1'6` 'L
(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,
l: 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 forthwith comply with those provisions.
fDate;&—ol • Applicant ._
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety,
for a permit subject to the .conditions and restrictions set forth on his
application.
1 Each person upon whose behalf this application is made & each person of
whose request and for whose benefit work is performed under or pursuant to'
any permit issued as a result of this applicaton agrees to, & shall, indemnity _
hold •harmless the City of La Quinta, its officers, agents and employees D
2. Any permit issued as a result of this application becomes null and void i
work is not commenced within 180 days from date of issuance of suc
permit, or cessation of work for 180 days will subject permit to cancellatio .
I certify that I have read this application and state that the above information
correct. I agree to comply with all City, •and State laws relating to the buildi I
construction, and hereby authorize representatives of this City to enter up,
the above-mentioned property for inspection purposes.
,,Signature (Owner/Agent) Date r
BUILDING PERMIT PERMI
;
I f
DATE VALUATION LOT TRACT
,�➢tt 14 z
JOB SITE
ADDRESS o��J Ufa 3 r � Ea►u 1I�t.'� y
APN 7' 15-011',
OWNER
CONTRACTOR / DESIGNER / ENGINEER
I\Tl ulPR,(Y1. R.'�`9 WC
3OLL } 'U' r �.�ci Nc
74.92.4 110VELY 1ANE Y= MMEYI.1220
74-9231410VI L1q3JF . "r 8UU1.UT -2 0
PALUMSEW CA 92260
PALIl1;I D-MiRwr CA 92260
f16(y)614-9699 C:.SLO 3132
USE OF PERMIT
W8115=1
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SALES orknc& 26.03 y41A uffit t, 17A w1 A [OiDa..
X7414"y t•3 Dec 1YPJ%14CY'avbfi 001,4S'9icZ. CT10m.
ONTRAXTT AMOUNT S.koftoo LO
i
1 il✓ 6 09r IV.L' _n14i:1 r1R1;Cr.L.$`liA'1
1.0.000.00
��'4j:.�ip�,Sdi'.0
Cak TRUC:TION 3EF. 101 -000-4 164100 $1171,00
MECHANICAL P- 101.000,421•000
21ECTIUCAL PKAT 101.000.420-000 0.00
PlAimDr9a FeR 101.000-419.000.
"sTRON'O MOTION PEZ ,- RMSID 101-000-241-:100`3
h
' 'wWA,
1.r0T.J%r1MA9.rrEES.01fr. Holy
OCT
LCffY0FL.AQU1N*TA
RE •DAfTE BY, DATE FINALED INSPECTOR
1
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
-tea
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
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING AP ROVALS
Gas Test
Electric Final
Waste Lines
'y
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)
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) cm
COMMENTS: �)