9903-184 (BLCK)ts: _• � • r �; x - LICENSED CONTRACTOR DECLARATION
. {' 1 hereby affirm under penalty of perjury that I am licensed under provisions of
U)
',Chapter 9 (commencing with Section 7006) of Division 3 of the Business and
N'.W i Professionals Code, and my License is in full force and effect.
License,# '• '" F Lic. Class Exp. Date
'CY L0
Z r— vDateignature Q ' ontracto?"`�----
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~'C) " OWNER -BUILDER DECLARATION
W W , I: hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
Z . (`):, •.1, as owner of the property,'or my employees with wages as their sole,
'.:" 4. 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
s 4 Code);;."
stj O I am exempt under Section' - , B&P.C. for this reason
`N Date 01Signature of Owner
{N r
aQ y WORKER'S COMPENSATION DECLARATION +'
Zcc I hereby affirm under penalty of perjury one of the following declarations:
Lo Q `..
r p O ` I have and will maintain a certificate of consent to self -insure for,workers'
X .W:LL compensation, as •provided for;by Section 3700 of4he Labor Code, :for;the
J Q pertormance•of-the work for,which this permit is issued. -
Q;;I�have and will maintain workers' compensation insurance, as required by
Section, 370'6 of the Labor Code, for the performance of the work for which this
CL, Lo. H permit is'Issued. My workers' compensation insurance carrier '&•policy no. are:.
' s , Z Lamer,
Policy No..
�'(``($a''tCJa. N1Wu249I..
s section need not be completed if thepermit valuation is for $100.00,or less
nF �Q (This P P )•
O I certify that in`the performance of the woyk for which this permit is issued,
I shall not'employ any person in ,any mann f so as to become subject to the
workers' compensation laws of California nd agree that if I should become
subject to the workers'. compensation prwlons of. Section 3700 of the Labor
Code, I shall forthwit o ply with'thosQ/�r visi
ons
.. `.
Date: l?;/j��plii,cant
t / t
•• Warning: Failure to secure' Workers' Compensation coverage is unlawful and
shall 'subject'an employer to 6riminal 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
permit subjecY,tothe conditions and• restrictions set forth' on his
application:
1:"Each person upori whose behalf this application is made & each person at
•' , r',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
is & hold harmless the City of La Quinta, its officers, agents and employees.
?:'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, :Dr,cessation of work for 180da ,s will subject permit to cancellation.
I certify that I. have read this applicatio and. state that the above information is
correct. I agree to comply with' all CJ,�, and State laws relating to the building
i•, '. i construction, and hereby authorize. ep'resentatives of this City to enter upon
theiabove mentioned property.for ��isp ction pL poses.
Signature.' (Owner/Agent)• / Date
.� '�� V+,y�'.'. '.`'."'.•;r�,.� �l "•:`�- -e -_1�. •i-�.�.. � tea.-,-s•.,i
BUILDING PERMIT PERMT/i ��.
��193-:1��
DATE. / VALUATION LOT TRACT
JOB SITFE
APN
ADDRESS 80,82 1 V N1A:L. ,0
_
OWNER
CONTRACTOR/DESIGNER/ENGINEER
]kiM +~OKN'ELL
A &.M, CO NS'tRUf f'.I.ON
LA QUIN17A CA 92253
LFA WN:
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
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
Set Backs
Electric Bond
Footings ZZ
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
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
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)