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0210-181 (PLBG) LICENSED CONTRACTOR DECLARATION PERMIT# U) I hereby affirm under penalty of perjury that I am licensed under provisions of BUILDING PERMIT I— Chapter 9 (commencing with Section 7000)of Division 3 of the Business and % U) DATE r VALUATION LOT TRACT 04 LV Professionals Code,and my License is in full force and effect. ► �CA�{t!"� �$ , �w License# Lic.Class Exp.Date ,✓' JOB SITE APN O L 48393 C36 C20 fn" `!'r I� ✓l L ADDRESS 459� ~ u�VT,�..A D _ C:) Z r- /,Datef/�,j ~ Signature of Contractor ��^"^"" OWNER CONTRACTOR/DESIGNER/EN INEER (Oo �� ( �+ F OWNER-BUILDER DECLARATION LOI�'LS1�t5'.�'3,'' �'ia�LX^' 'tYZX 3_rkTG �:�IM W d r- I hereby affirm under penalty of perjury that I am exempt from the Contractor's 49.603 AVILA DRXEI 7 pALES •M R0 U) License Law for the following reason: 1A,QUNZA tom, 922,.SS pfilm DFZM.•i CA 922,60 . 11 Z_ ( ) I, as owner of the property, or my employees with wages as their sole 0603416.6758 " � E" compensation,will do the work,and the structure is not intended or offered for sale(Sec.7044,Business&Professionals Code). USE OF PERMIT ( ) 1, as owner of the property, am exclusively contracting with licensed , �� , contractors to construct the project (Sec. 7044, Business & Professionals Code). EPTICAa€i.7ti13:AC3ATMIKNT;S WSR HC10K41P C0 () I am exempt under Section , B&P.C.for this reason U') N Date Signature of Owner O Cil 0)d Q WORKER'S COMPENSATION DECLARATION C) 2 Z I hereby affirm under penalty of perjury one of the following declarations: r H O O 1 have and will maintain a certificate of consent to self-insure for workers' �YAI� 'T3CC:»fJ 43'flEtfp'00 Ln X W LL compensation, as provided for by Section 3700 of the Labor Code, for the mJ Q performance of the work for which this permit is issued. Q () ( ) I have and will maintain workers'compensation insurance, as required by O U Q Se(ction 3700 of the Labor Code, for the performance of the work for which this a H permit is issued. My workers' compensation insurance carrier & policy no. are: Z Carrier STATE FUND Policy No. 1.$09498<4I F.313x llu)COY..r'UP 5::OMENUMION ��,��1.6�•D J (This section need not be completed if the permit valuation is for$100.00 or less). F+LtTm1 ig,I'm, 8 r. Ell MOM ( ) 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 subjectIo the = t workers' compensation laws of California, and agree-,,that if I Phould;tecome " subject to thej�vorkprs'compensation provisi? s of-Section 3700 ofdlhe Labor Code,I shall/forthw!-ith comply with those'_p'r'v�,sion .�,.�,. -- I 1 CJI Applicant F 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 U addition to the cost of compensation,damages as provided for in Section 3706 of the Labor Code,interest and attorney's fees. CITYOFLAQUINe, IMPORTANT Application is hereby made to the Director of Building and Safety FINANCEDEPT 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 r 9•�UCT1,011 H�xllaN O�I�.��K whose request and for whose benefit work is performed under or pursuant to �;xLi ') I"'2�T'<T3J�1 J I• (S tIC 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 TOTAL 11MRAW; `EES A7I.I'."NOW 0Al 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. III�IIIIIIIIIIIIIIIIIIIII 56 I certify that I have read this application and state that the above information is 4 representatives, I ws rel5ting to the building / IE correct. I agree to comply with all City, and State J construction, and herebyauthorize �of this Cit to enter upon the above-mentioned property for inspection=purposes � �' _ RECEIPT DATE BY � DATE FI ALED INSPECT !S gnature (Owner/Agent >'`""ti�� ~' Date�� Y2 " �'' � ' "' r INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Underground Ducts Forms&Footings Ducts Slab Grade Return Air i Steel Combustion Air I ` Roof Deck Exhaust Fans ' O.K.to Wrap F.A.U. Framing Compressor j; Insulation Vents i Fireplace P.L. Grills Fireplace T.O. Fans&Controls Party Wall Insulation Condensate Lines i Party Wall Firewall Exterior Lath Drywall-Int.Lath �r Final ^}y. Final POOLS - SPAS BLOCKWALL APPROVALS steel +� Set Backs Electric Bond ,i Footings Main Drain 4- Bond Beam Approval to Cover Equipment Location Underground Electric ( Underground Plbg.Test final Gas Piping ft PLUMBING APPROVALS Gas 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) P——17 1 ELECTRICAL AP ROVALS 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) ,e \< C10 Vit. .VAL[; 1. Mt D18TiNOT H R[lmlf►P"T I AIL r� fl _ ' ft Reoaived.Fro Dete' lu O Add?sm. k66 �K4 - A000untNo. - 4o(e) ' Tnratr Servide Address Meter(s) 1 " Ci House L°>iEoral(o) n Mtersurcharpe ? ' Sanitatic'n-pipeolty 0hit pe . •s. - `y:-- e : - j Ali if yc�t ? Cn ❑.Ten�porar�0ari>rtruaflon Mlter�' t _ -r ,. .� �' -3 -�}'" .. © Turrtdn Chirps 0 Unoolleotbd.Account=Nsi ii Q Inspection Pre-Treot- Pee- it, _ M Plan Check Post Water t-S&V- Fsi 7 tTreot- ► .r yC7 Sond r 3.{.• 17 0 Oubtomerpo osit �. Other. 4 T Rbr<terkel+ w lAA li'V4liJ.)L tai - K Y 1: Mbney . F .� a Order Oaahler. _OVWtl•4SB{1t18A)