0205-102 (RR)I iuN
A,
C/) I hereby affirm'under penalty of perjury that I am licensed under provisions of
Chapter 9 (ccimm�encing, with. Section 7000):of Division'3 of the Business and
R 04 LLJ Professionals Code, and my License,is in full force'and effect.
License # Lic. Class
Lc V) Exp. Date
It_ -Cy U)
LLJ 511457 (13 9
oZ Signature of Contractor
.0.
CD OWNER=IBUILDER DECL:A A ION
;;LJJ
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
Lu r
0-
U) License Law for'thblollowing reason:
Z 1, as owner.of-the property, or my employees with wages as their sole
compensation, wili'do the work, and thestructureis not intended or offered for
sale (Sec., Business & Professionals Code).
a�. owner, of -the'* property, am exclusively -contracting with licensed
•c 6 r
In i �r - -a c t 6 r sto, 'cons ct- the project (Sec.. -7044, Business & Professionals
7 , t U
106d'6*),
CV)
j,+iKexempt .:Onder Section,. B&RC.Ifor this reason
O'N DateL"Signature of .Owner
WORKER'S COMPENSATION DEdLARATION:
-01: hereby- affirm -under penalty of perjury '
Lo,:.< , one :of the following' declarations:
have and .%�ill maintain a certifidaie'of consent to self -insure for wo'rkers'
compensation , ,;as-,provided'for'by Se6tion 3700 of'the Labor Code, for the
performance I
a ormance o' the -work for which this permit is issued.
0 1 h and will
ave a maintain workerscompensation insurance, as required by
on 3700-of.the La66r.Code, for the'performance of the work for which this
0— 0)
U1
�-,., W' mpensa ion- . permit is issued'_My orkers'. cc insurance carrier & policy no. are:,
-Policy No.
C6
may ,>g
(T61ssection need ' not be completed if the & $100.00 & less).
__I,-Certity"th' ' " _ rf _ _ . the permit va uation is f
at in.the pe ormance of the Work for Which this permit is issued,
I-,sha11;nempIo`y
-any. person''in any manner so as -to become subject to the
workers --compensation k --compensation laws. -,of California; and ag`re&`that if I should become'
.,.,
44 N." subject to the workers' compensation provisions of Section' 3700 of thg'Labor:
�
6ISfiall forthwith comply with those'provisi 6s).
v'3� Date`,;.Applicaht_
c
'Varnlng:t!Fall re10
secure Workers'z Con;R'64A's ti oerageAs lawful .and
�!
re penalties and civil fines up to $100,000, in
iii subject an.einploye-r,to criminal ''
,"��laddi.i.ion,tothe b'ost.of -compensation,, darnages.As provideflor in Section 3106
of
r
MP RTANT
ocie4 interest and attomey's' fees.;.
'Application i6'hereby made to the' Director of Building and Safety
f& permit subject to ;the conditions and restrictions set 'forth on his
app '
Ii ti n.
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 6 result of this applicaton agrees to, & shall, indemnity
its officers, agents and employees.
& hold harmless the. City of La Quinta,
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.
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
:aconstruction, and hereby authorize representatives of this City to enter upon
-..,..../.BUILDING PERM PERMIT #
02WI02
.VALUATION
,
DATE.LOT TRACT
JOB, SITE APN
ADDRESS g '5
P0A WWRT IMSIDMnAl, HOMR-MMERS
P.O. K)X-1069
1,AQUWFA
USE OF PERMIT
OPNERAL 13IALDIN0
'n-lY ".1-0-1811MM OF (2ALVID iA, 0C.
157-555 FAST PATI M. CANYON DRIVE
CAT)FfRDRAL CITY CA KiQ
(769)325-91.11 (M L#- 4611
R&ROOF01TH Cf.ASIS' A. h44WRIM-14- BIJXJ. 549491,
114-437,Ffi-40 OAKFULL
2.,946.;X0.,&
PYAMIT FER FAIMMAkY
I . zwwsq IT. L? S30m
PQ o
1 FMAY, U`100Z
C00FLAQUINTA
FINANCEDEPT
. TALCON40,17tAX-FIONAND
-LEPV,�
'rth 4bove-mentioned property for inspection purposes.
RECEIPT DATE
..Signature (Owner/Agent) Date
PV.Rmff FEWS "OVY, x0W
rJ0,00
IV). wi
M00
INSPECTION RECORD
OPERATIONDATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck •-p
O.K to Wrap
Exhaust Fans
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 APPROVA S
steel
Set Backs
Electric Bond
Footings
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)