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9907-020 (SFD),. _ _ , LICENSED CONTRACTOR DECLARATION Zj'f hereby affirm underpenalty of perjury that I am licensed under provisions of ='Chapter,9 (commencing with Section 7000) of Division.3 of the Business and Professionals Code and my License is in full force_ and effect. License # Lic. Class Exp. Date r/• t y/Date— Signature.of Contractor "-�~, OWNER -BUILDER DECLARATION Y 1 hereby affirm under penalty of perjury that I am exempt from the Contractor's, . License Law for the following reason: ( ) •l, 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). f ( ) 1, as owner of the property, am exclusively, contracting with licensed contractors to construct the project (Sec. 7044, Business & Professionals Code). \" O J am exempt under Section B&P.C. for this reason Date Signature of Owner WORKER'S COMPENSATION DECLARATION I 'hereby affirm under penalty, :of; perjury one; of the following declarations: " ( ) I have and will maintain'a-certificate of consent to self -insure for workers'. compensation,,,as"provided'foF`by Section 3700, of'the Labor Code, for the performance of the work for which this permit is issued. ( 0)� 1• have and will mainfair' workers''compensation insurance, as. required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation insurance carrier & policy no. are: Carrier— Policy No. , ii ' �,L.C. A.R.}�.�IJ�YI�✓ `. ,. ll`�4."S7il�!...: 3�th (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 bpeSpjne sbjectto the workers' compensation laws of California and agree -that if I sho, become subject to the workers' compensation provisions+of Section 370 of the Labor Code, I shdfort4wl , comply with;those prwislons. { Date: Applicant t: � f Warning: Failure to secure Workers' Comp�'eMafion 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 whose request and for whose benefit work is performed under or pursuant to 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 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 correct. I agree to comply with all City, and State laws relating to the building construction, and hereby authoriz _representatives of this City to enter uponr - the above-mentionedroperty or inspecilon purposes. $Ignature (Owner %Agen Date ' d� BUILDING PERMIT PERMTN _1S,40.4 DATE VALUATION '_ ,r LOT TRACT JOB SITE S� ADDRESS 0Y%tY't17i4�WLOtALY••�' APN �• YY��3-lGF 4tUf s t OWNER c . ' t < CONTRACTOR /DESIGNER /ENGINEER 4101 al,±.,.•V6.:i,a�..i:��4 gfi>_4i,JZ'',ii)'+.1f .ice tilf1'll�;ilz�.! vV.�\.iji,. A..�.'./iVs ` 79-295 ;[2ANC.HO L.A. QUIN r1k DR. :l.Ei r Cry. 92253. LA QUINTA CA 9-'n53 Y USE OF PERMIT ' e SW01, l "f i.AWLV DW8LLFNG $WD iiiPLAN WR, PE (iWESNOT 114CLUT)E BLOCK LALI. - . RLOOL-. 75'0/e PLA;LjyfK F3 kEDU NOIN SRY-91i1 1APLE 3S§U11Ns1fZ SflW P1.WINK,,! CUSTONT C(ANSMUFMION 3556M SF l�C31"GC"t�i/YFr'i'f© 44t5.00 SI" 'GARA(MCI ORT• E':3fi.i SF. e• G'.'n .4'!1.1IX Ar'D COST 1J.6"+I�vM.71'V.2-, 114.. CONSTRUCTION YBE 10tAX10-41$-Q(ii'1 $L325.50 P,11.0 C'}dF}C`lw FRE, TNMQAL s� kZA3 BELEI .'°TRICAL F ice; ' PL`C3ibiBING E•"lEE S229,0.0 'Ifi1�C?Nl jb C3'Trf ril f a f? w 'frig 1{1�. {lft- '31 ► 1? :9 54 unwuw mc $200 if MA.S'TR(fCrURi FhX' $4,600.00 . :... . A '1' J.A<f.i tJ .i.l'c 1'.laA�:. ^� d21 titG �k-iki?U-X55-Qt>Rtsupi,52 . ,'.UY',I.L,'rAT.CON'S ML?i,,r1,6..tLVAfl, tl.E'?\ r3J.E1.,'K LESS PF.'E••I."t,ID FEES Vioi . KA'All, PERP lit lt? t%..;€ 134: f?i��0?V S ,1 k9.' S . k RECEIPT, DATE BY l DATE FINALED INSPECTOR INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION T DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs - Underground Ducts Forms 8 Footings Ducts Slab Grade Return Air Steel Combustion Air Roof Deck - G1 Exhaust Fans O.K to Wrap ! _ -C 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 oo Drywall - Int. Lath - / Final cv Final BLOCKWALL APPROVALS POOLS - SPAS 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 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) COMMENTS: