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0307-199 (MFD) t . v LICENSED CONTRACTOR DECLARATION PERMIT# I hereby affirm under penalty of perjury that I am licensed under provisions of BUILDING PERMIT Chapter 9 (commencing with Section 7000) of Division 3 of the Business and DATE VALUATION �u , :{ ,,c�I) LOT 2R;� TRACT i < y t14 W Professionals Code,and my License is in full force and effect. O =) ch License# C Lic.Class Exp.Date W to I M.?'11 T f 3 ADDRESS v APN d 1 C'1 ;`.i i.o r1TC ?. da�,� 37; t. + 7 ; x:1:�Z ?t1,�? n PT-3 Z +Date` s. �� Signature of Contractor-•-- I - OWNER CONTRACTOR/DESIGNER/EN INEER Zo O !'j iW^'r: Nfvr I T 7 N r- I.- C) OWNER-BUILDER DECLARATIONTTRICIRME ,•.�k.:,�1 W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's GL DALE CAS, Y 120 �?�'�:;�wCYC1 ~ U) License Law for the following reason: %-5 5'' 7 , r a Z_ ( ) 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 sale(Sec.7044,Business&Professionals Code). USE OF PERMIT ( ) I, as owner of the property, am exclusively contracting with licensedk 17 �I'IRk�da"I��7d 7.1?ti� contractors to construct the project (Sec. 7044, Business & Professionals Code). ioix :s\ ML9is .t 14''i,;-.ut1Jo1:.4G' Cf) () I am exempt under ecton Si —, B&P.C.for this reason I'E3tgr IT POE DICLUOV R O'."E W41-1, OR K,01, RINDI~' ED FEE O N Date Signature of Owner PERMIT OF"fill rn Q WORKER'S COMPENSATION DECLARATION u < Z I hereby affirm under penalty of perjury one of the following declarations: �tI� I��I�F?FI IV-1~X P.0 +g r FZ O O 1 have and will maintain a certificate of consent to self-insure for workers' 5,,e4is ii ur X W �= compensation, as provided for by Section 3700 of the Labor Code, for the COW'g'%K1 1,12 m � Q performance of the work for which this permit is issued. Q () 1) I have and will maintain workers'compensation insurance,as required by O U Q Section 3700 of the Labor Code, for the performance of the work for which this t1 rn f- permit is issued. My6l�3yt3p workers' compensation insurance carrier & polic no. are: � Z Carrier n,ilf�-` ftjC-v0 Policy No. 'o C3 :'iRSIMF�'�UITW('7C)FEO 4 INS:�.I:UC1'�'1aH 3261315.00 Q (This section need not be completed if the permit valuation is for$100.00 or less). CONiUC I IO'N M f't p.000-4173-OW ffi'_•A4•0 ( ) 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 1A CyE).ANACSALF I( SGtI-0041421-000 $470,00 workers' compensation laws of California, and agree that if I should become Sa XTR1C AL 9,x•9 101_000-420-00 iina,0 subject to the workers' compensation provisions of Section 3700 of the Labor I'IatIMBIVICp}a }011.4lU101,4'1 9-0M) Mt...50 Code, I shall forthwith comply with those provisions. STAO,NO�AOTIOIN'"EF•kd1V'�tt:, ?-UC0-241.00:� Date: c I Applicant--- - 1U, 1 CII'e.Afiil'rlt FZE, 101-Otf(lAV-00:a 9 .1(1 . Warning: Failure to secure Workers' Compensation coverage is unlawful and IM1510pP:Tt)NIPIACT FIrc�, shall subject an employer to criminal penalties and civil fines up to$100,000,in AM IN PUB14C NACES-R':.sir Xy0_(W0445_(X,-' addition to the cost of compensation,damages as provided for in Section 3706 of the Labor Code,interest and attorney's fees. IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the conditions and restrictions set forth on his application. 1. Each person upon whose behalf this application is made&each person at whose request and for whose benefit work is performed under or pursuant to `� (1 1 s�'�� i" •A� Y�- ': `sus 0© any permit issued as a result of this applicaton agrees to, &shall, indemnify �, & hold harmless the City of La Quinta, its officers, agents and employees. 2.Any permit issued as a result of this application becomes null and void if AUG work is not commenced within 180 days from date of issuance of such U 0 1 003 permit, or cessation of work for 180 days will subject permit to cancellation. ---------- I certify that I have read this,application and state that the'above information is CITY OP LA QUINTA �-IIIIIIIIIIIIIII�IIIIIIIII 7$ correct. I agree to comply with all City, and State laws relating to the building PI';a:°CE�T construction, and hereby authorize representatives of this City to enter upon IE the above-mentioned property for inspection purposes. 11 RECEIPT DATE BY DATE FINALED INSPECT l .....«.^ t Signature (Owner/Agent)*'-^^ •-�-^�.� Date 11 0 �i w; INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Underground Ducts Forms&Footings Ducts Slab Grade ` Return Air Steel y Combustion Air Roof Deck < y 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 L , 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 I 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 J 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 I G.F.1. / Smoke Detectors Temp.Use of Power Final Utility Notice(Perm) L-a- ��� ' i e of OccupanCY Cert�f cat r?. I•cawoonTrnMu 4 G� OF' 4� Building. & Safety Department E fi This Certificate is issued pursuant to the requirements of Section 109 of the California Building Code, certifying that, at the time of issuance, this structure was. in compliance with the . a provisions. of the Building Code and the various ordinances of the City regulating building construction and/or use. z BUILDING ADDRESS: 78-875 AVENUE 47 BLDG #F } Use classification: R-1 Building Permit No.: 0307-199 I 3 Occupancy Group: MFD Type of Construction: V-N Land Use Zone: MFD f Owner of Building: SCPH Address: 516 BURCHETT STREET City, ST, ZIP: GLENDALE CA 91203 � j By: G.SHOWALTER 1 —�° Date: 01/03/05 Building Offi ial i POST IN A CONSPICUOUS PLACE