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0004-266 (SOTB) LICENSED CONTRACTOR DECLARATION ,, t PERMIT# I hereby affirm under penalty of perjury that I am licensesunder provisions of �. .` t( BUILDING PERMIT H Chapter 9 (commencing with Section 7000) of 61 the of the Business and 0i ~� DA IE VALUATION LOT TRACT W Professionals Code,and my License is in full force and effect. �0t3pAtCl O =) ch License# Lic.Class Exp.Date Imo,0! 1 ' JOB SITE V,1 APN � w 7 'Sl 131 1tTJ311 t ADDRESS 4,9-622 VRM r' �fr� rt� l: Z r-- `Date Signature of Contractor 's OWNER CONTRACTOR/DESIGNER/EN (NEER cD O. , r- o_J CID OWNER-BUILDER DECLARATION 81ELBY Sc7twiBER EAOTOkl tBU11.1"3.0-RS C ORPOR.AT101; W w Il- I hereby affirm under penalty of perjury that I am exempt from the Contractor's 09 02�t,.�I�VV AD�RUIVE h 0 BOX 3235 ~ N License Law for the following reason: LAQIY&.rA CA 92253 PALM ZJ iLrr CA 92261 Z_ ( ) I, as owner of the property, or my employees with wages as their sole (760)772.1631 CRL0 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 © contractors to construct the project (Sec. 7044, Business & Professionals U 3 Code). INST.".L.LATION OF INTERIOR.F'.A.8R-1CA`l'PD#1RZP1 ACZ LCV)O () I am exempt under Section , B&P.C.for this reason N Date Signature of Owner ON Q1 d Q WORKER'S COMPENSATION DECLARATION o CcI hereby affirm under penalty of perjury one of the following declarations: - 1-2 O ( ) 1 have and will maintain a certificate of consent to self-insure for workers' VALuAT101r Lm, X W LL compensation, as provided for by Section 3700 of the Labor Code, for the O J Q performance of the work for which this permit is issued. C0 Q I have and will maintain workers'compensation insurance,as required by O V Q Section 3700 of the Labor Code, for the performance of the work for which this 4 rn H permit is issued. My workers' compensation insurance carrier & policy no. are: v z CarrierEXEMPTPolicy No. K511,' *=COST OF C+ONS'T'R•!1'C Tom s,t omoo C) PIMAW FM KIWAARY J (This section need not be completed if the perryrtvaluation is for$100.00 or less). 1st CK-CK FEE 101-000.439-318 146,811 ( ) I certify that in the performance of the work for which this permit is issued, to an I CO1�STRUCTIOU I 101-000-418-000 M.00 I shall not employ y y person in any manner so as to become subject to the workers' coftensation laws of Californi / r d agree that if I should become PLUMBING FER 101.000-419-000 SI&C# subject to the woh�kers'compensati n v sio s'of Section 3700 of the Labor STR.ONO MO'YIOX FFZ•RESID 101-000-241-OW $L 0 Code,I shall�oitfiw'th comply with thos f rovisions. Date: `� Applicant- SN, f J 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 at SUB TOTAL C:OzdS"1�2U07-10W" PL"Ck-MC $13130 whose request and for whose benefit work is performed under or pursuant to S P M. -PAID�\ any permit issued as a result of this applicaton agrees to, &shall, indemnify map & 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 TOTAL 1'14:RMff+'1�SDUE NOW work is not commenced within 1x80 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 applilation and state that the above information is IIIIIIIIIIIIIIIIVIIIIIII �� ' correct. I agree to comply with all\City; and State laws relating to the building 60 construction, and hereby authorize representatives of this City to nter upon IE the above-mentioned pr pertt fo Inspection purposes. { J !/,a j RECEIPT DATE / J` ` DATt;IN � � INSPECTOR Signature (Owner/Agent) ' Date INSPECTION RECORD Ii 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 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 I} 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 I 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)