0205-114 (RR)LICENSED CONTRACTOR DECLARATION PERMIT#
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I hereby affirm under penalty of perjury that I am licensed under provisions of BUILDING PERMIT
(commencing Chapter Cha 9 in with Section 7000 of Division 3 of the Business and i�
p ( g ) DATE ,. � VALUATION LOT TRACT
v'w Professionals Code, and my License is in full force and effect.
(r) License # Lic. Class Exp. Date
LO JOB SITE APN
LV 114 .'t t,?'>.� ��:,0/013 ADDRESS E�[al>r,.'�..tiE� C���.Fb s'.��1.;I. " t%)5
1., •• OWNER CONTRACTOR/DESIGNER/EN INEER
Z r �te Signature of Contractor ''r '!
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H OWNER -BUILDER DECLAiAl`ION
_J U r1_ j -0. j Q*1 1. ) 060Yi I - `;;. ;{i:° a f. !',�a.:iJl r: i' i �' ':. 1`•I t7a<. `; .i J-
L W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
— d LAiu f) c i�±'.j'��s.
Z( ) License Law for the following reason: I, as owner of the property, or my employees with wages as their sole ;'ri i}i):�� ` 'a I I'• C'.i .Llf ir•:; i
compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code). USE OF PERMIT
( ) I, as owner of the property, am exclusively contracting with licensed IT. lFf� (ii 1?f 11f 'I'•:Y
contractors to construct the project (Sec. 7044, Business & Professionals
Code). 1%U•fitlif'' lW,'1':Il t::LA; ;.A It.`�7'rsf�t,�L.:�• ti,t,3ii.i. WO; 't•U
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O I am exempt under Section , B&P.C. for this reason ,?, 1)4!>:I ! i.,�r,Y: ) !11 •f .
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Date Signature of Owner
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0< WORKER'S COMPENSATION DECLARATION
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Cc I hereby affirm under penalty of perjury one of the following declarations: �rj;j,(ir1`).')si.ti
_ O ( ) I have and will maintain a certificate of consent to self -insure for workers'
LU Y= compensation, as provided for by Section 3700 of the Labor Code, for the
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Q performance of the work for which this permit is issued.
Q U ( Y I have and will maintain workers' compensation insurance, as required by
ju Section 3700 of the Labor Code, for the performance of the work for which this
U-) H permit is issued. My workers' compensation insurance carrier & policy no. are:
� Z Policy No.
OCarer :JTQTY �td) ftl}._ C,1! i fff.:3�t t'
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�°lc: di'�R t+'�f�:.. UM"i a:a1RY
J (This section need not be completed if the permit valuation is for $100.00 or less). I'WjrOI-)t III"k; l01 00
() 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
3 subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions:
Date: I- Applicant—
Warn ' ing:
pplicant Warning: Failure to secure Workers' Compensatlor4overage is unlawful and `{ i;, ' i i
shall subject an employer to criminal penalties and civil fines up to $100,000, in ! ' °} ✓ /_ .l
addition to the cost of compensation, damages as provided for in Section 3706 CITYOFLAQUINTA
of the Labor Code, interest and attorney's fees. i
FIPIANCEDEPT
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 „1:.!{ .'(`is17`:� t, f_:i 3)f;fT i�1..1t."a`,[ 1Pa AN",) t'i_A� ,f r:�.£•Iti;(',K.
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 �ir1'.f'� 1111:Et'1 .1�j`:�°�isP:':`_i T�I.Iit. NOW +.;�(► {fig
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 f
the above-mentioned property for inspection purposes;`_. RECEIPT DATE ;' BY DATE F ALE INSPECT
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Signature (Owner/Agent)q �'' Date `'
OPERATION j
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel _ . /
Roof Deck �/
Combustion Air
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
Main Drain
Bond Beam
_
Approval to Cover
Equipment Location
Underground Electric ^
Underground PINI 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 y (
Pool Cover ;
Sewer Connection I
Encapsuiation
Gas Piping
^ ,_
Gas Test
Appliances
Final
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COMMENTS:
Final_
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Utility Notice (Gas)
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ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring -'
Fixtures
Main Service
a Sub Panels ^_
Exterior Receptacles
G.F.I.
Smoke Detectors
I
Temp. Use of Power
Final
Utility Notice (Perm)