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0312-157 (PC) LICENSED CONTRACTOR DECLARATION PERMIT# U) . I hereby affirm under penalty of perjury that I am licensed under provisions of BUILDING PERMIT 0312-x.57 .I— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and DATE VALUATION LOT TRACToe N w Professionals Code,and my License is in full force and effect. License# Lic.Class Exp.Date Lo 9301 J7 3 /� // C}JI 11 P2,f ADDRESS 101 SITE `78;g CTA APNUJ - O Z r— _� /Z•12tl l� f f/( Y OWNER r CONTRACTOR/DESIGNER/EN (NEER O �✓ Date Signature of Contractor - CD H OWNER-BUILDER DECLARATION VIS"T.�TAQU 'ST1 J.XCy (')I12J3'C7MDERS -J U CID45 F d4 '�}jr"1.3f, �' 39a�01 T�?�( CiF! :3T13 'T X00 W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's p a- 3:ID1© �, A 92201 PAI1`./I MORT CA 9220i U) License Law for the following reason: Z_ ( ) I, as owner of the property, or my employees with wages as their sole (7. 60)360•£032 CB114 :395 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 COW+LFM AL contractors to construct the project (Sec. 7044, Business & Professionals Code). 234- SHADE,-1-1-RUCTU (A4Z'rAL)i14 TYPE E L ICtHT IfI TUnS TO CY) () I am exempt under Section B&P.C.for this reason HOU89 p.APf�;UC.t?1J.Gi.1''f'�tC+VAL PER MED BAKER,2001 Ci2'_`< N Date Signature of Owner ON M FL Q WORKER'S COMPENSATION DECLARATION IO Q cc I hereby affirm under-penalty of perjury one of the following declarations: Pt71Z�• S��T 1� Oa1, r H O ( ) 1 have and will maintain a certificate of consent to self-insure for workers' X W l� compensation, as provided for by Section 3700 of the Labor Code, for the O � Q performance of the work for which this permit is issued. m Q I have and will maintain workers'compensation insurance,as required by Q (-) Q Section 3700 of the Labor Code, for the performance of the work for which this 11 0) H permit is issued. My workers' compensation insurance carrier & policy no. are: 141 Z Carrier STATE FIJ14D Policy No. 1212824-02 NS 11107D COST OF C0Xg51' UCrjl' ON 3a112.20 Q (This.section need not be completed if the permit valuation is for$100.00 or less). PAN CHECK FFP 101.0,00-439.31 S $40.95 J I certify that in the erformance of the work for which this permit is issued, ,11 t+ ( ) Y P P CC�x�.r 1`..,.tJC"1'hCiad.F"FE 101-000-418-000 $610D I shall not employ any person in any manner so as to become subject to the &LECU4C.EleFEF, 101-000.42.0«000 $75,50 workers' compensation laws of California, and agree that if I should become STRO1401V1L'TION'FEEL C'O.MM 100-000-241-000 $.61 subject to the workers' compensation provisions of S ction 3700 of the Labor Code, I shall forthwith comply With those pr�vjsions Date: Jg b`1 Applicant 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 4 application. 1.Each person upon whose behalf this application is made&each person at WB-MTAL CMMIRY.M."ON ANrD PLAN C'•ImCK $130.10 whose request and for whose benefit work is performed under or pursuant to 1E yS 1•RE-,'.A.ID FEES $0,00 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 (j /�=+� 1 � � ^�1"n�'�s mm:_ow ��-� •g0' 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 2 LOQ I IIII�I VIII II VIII IIII 08 correct. I agree to comply with all City, and State laws relating to the building C onstruction, and hereby authorize representatives of this City to enter upon CFIA[V>�QIMTA IE the,above-mentioned property/for i.spection purposes. __ T / RECEIPT DATE BY DATE FINALED JINSPECTOR �� Signature (Owner/Agent) Date INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Underground Ducts Forms&Footings ?i a 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 O POOLS - SPAS BLOCKWAL A PROVALS 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)