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0307-268 (BLCK) LICENSED CONTRACTOR DECLARATION PERMIT# CO 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 DATE VALUATION C 75 LOT TRACT LL Professionals Code,and my License is in full force'and effect. License# Lic.Class Exp.Date APNOdi; . t Y� 1013 SITE mo G2 ADDRESS LU _ Z Date '_�� Signature of Contractor •�` l ^r � OWNER _ CONTRACTOR/DESIGNER/EN (NEER O r 7 fr' ww�l � ��d rl° r�i! .�i'7 :U ix. C. ��c�'G `f�L�?., 't�"�I f A.-SYqSCt, ';iP MA. r— I.— C) OWNER-BUILDER DECLARATION AVERT. aW I hereby affirm under penalty of perjury that I am exempt from the Contractor's P0 Box I 10 FZ-100 1,kQulkr a= CA 912K', C,, 9V36 N License Law for the following reason: Z_ ( ) I, as owner of the property, or my employees with wages as their sole i/F.;4) 3 �#•3a,�f: 0,731., 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 licensed3 .�i.t'►1.. .11l,.i?1't�{3 contractors to construct the project (Sec. 7044, Business & Professionals _ lylw_ Code). r� ,V.W^u .. x— i+ry17/f V'61 4Y'wi`7 oI! iAY.C~ h,7L YlY{~ ♦tJ Y Y A u ,.Y MW,.. C•`) () I am exempt under Section , B&P.C.for this reason LO N Date Signature of Owner O � Q WORKER'S COMPENSATION DECLARATION C:> I hereby affirm under penalty of perjury one of the following declarations: 6 111T, 'MALL �``W L Lo H O ( ) 1 have and will maintain a certificate of consent to self-insure for workers' X w compensation, as provided for by Section 3700 of the Labor Code, for the 0J JQ performance of the work for which this permit is issued. Q (> (.),J_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 rn F<: — permit is issued. My workers' compensation insurance carrier & olicy, no. are: ,z ,,, 4 ,, It z Carrier `)FATE C0MPE.;d'dRATI Policy No. wry•616�-NQ3 �l�'I'#I�<1��.1�C'OE-T IDT'i.f.)MIRUCT1,0Y, Cb a a: 3+4:.11;�ti'�Off"I Y J (This section need not be completed if the permit valuation is for$100.00 or less). ( ) 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 workers' compensation laws of California, and agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions. Date: !� f Applicant :•. ZY ze y 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 .. "'=' 'k" f° � �` , r pq j� �, r rr rr� `43.00 whose request and for whose benefit work is performed under or pursuant to (� ,;jS,i;U PRE-P&,r,!jai; 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. .)"CJM Pf `moi KES DU £3p.IIN 1111}M JUL 2.Any permit issued as a result of this application becomes null and void if 2003 '° `" work Is not commenced within 180 days from date of Issuance of such 2 permit, or cessation of work for 180 days will subject permit to cancellation. . CiiY C� La C'llIC.TA 11111111 VIII III VIII IIII I certify that I have read this application and state that the above information is pl,+,�,';,::I'=t'T. 68 correct. I agree to comply with all City, and State laws relating to the building construction, and hereby authorize representatives of this City to enter upon IE the above-mentioned propertyAr`inspection purposes. - R ,� RECEIPT DATE BY (-I DATrE FINED INSPEC Signature (Owner/Agent) %� � ��'i ��^ Date �� INSPECTION RECORD 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 Pibg,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 j 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)