0105-295 (BLCK)LICENSED CONTRACTOR DECLARATION BUILDING PERMIT,PERMIT#
I hereby affirm under penalty of,perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Di iiio5,2 ofafhe Business and DATE VALUATION LOT 01 y, TRACT
Professionals'Code, and my License is in full force anpl effect.
License # Lic. Class /� % Exp. Date ?Za3. 7 1 I Eib 4 ! 4104,
�+N,•,� JOB'SITE APN
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D/ `a4�.270 ' �9 ' 03/31/2( ADDRESS S�i-��.�aC�`,£EtWO�B�ii�,� DRIVE'OWNER CONTRACTOR / DESIGNER / EN (NEER
ate ���• •����'���Signature of Contractor ''� s'.�<v-�
OWNER -BUILDER DECLARATION y +1 (5$ a it EZJR
I Hereby affirm under penalty of perjury that I am exempt from the Contractor's ,, d{ pp4 t,�pp�yZ.� ON NA •�� 23 2 VIhV'ti}
�Phw tl,..J.E `V'l.'O �l�"!C'��6f� � .+7�«v
License Law for the following reason: LA QilThT A CA 92253 F�.. 'ICTIO �b M?p, CA 92.2. 0
( ) 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 it3�a"z2 Cf' 313
sale (Sec. 7044, Business & Professionals Code). USE OF PERMIT
( ) 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 129 LIF 61 HLOC;'W'b'rrA;a3.,-ORCO STANDARD
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of'perjury one of the following declarations:
( ) I have and will maintain a certificate of consent to self -insure for workers' •b+��S .,fid �f''�,
compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
'(y )s I have and will maintain workers' compensation insurance, as required by
Sption 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 Policy No.
B�NT��a3i�3� -rnp, wo, li'~�+' .`CSS A:f o:� �ll'9 :&'S11JhgA,°$"��.9•V-'43;ST OF C-0, •K11Z4i(J'd Q1q
(This section need not be completed if the permr�it val6ation is for $100.00 or less). FERI F SUMMARY
() I certify that in the performance of theAorkFfor which this permit is issued, CONtu111vel�',low 1
I shall not employ any person in any mannerTso as to become subject to the
workers' compensation laws of Califoe "ia�nd agree that if I should become
subject to the workers' compensat on p ovisions of Section 3700 of the Labor
Code, I shall forthwith comply withitho'se provisions. '
Dater -., I ' .6Applicant//'.,,
/Warning: Failure to secure Workers' Compensatiomy,verage 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 SUB=TO" AT, PONSTR.+ C1109AWE,) A.c.. N CM -1(<
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. AM gr,_,�ti7?y3 $D_Oi.) li! Q} )
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 (jjj l"� MSDUE NO'4'Vl'
permit, or cessation of work for 180 days ill subject permit to cancellation.
I certify that I have read this application,,and state that the above information is 3 ®�
correct.:) agree to comply with all City„gnd State laws relating to the building
construction, and hereby authoriz�epresentatives of this City to enter upon
the above-mentioned property for,,inspection purposes.
RECEIPTFWHI'd By, D E F ALED INSPECTOR
d
Signature,(Owner/Agent)' Date''3
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 �_� (j ( _ _
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
_
Final �2�(
PLUMBING APPROVALS
Gas Piping
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)