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0304-346 (BLDG)LICENSED. CONTRACTOR DECLARATION Thereby affirm under penalty of perjury.that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business ander Professionals Code, and my License is in full force and effect. �r License # Lic. Class Exp. Date 4.51035 DMIC ./Date �� � fib' .Signature of Contractor`' OWNER -BUILDER DECLARATION I hereby affirm under penalty of perjury that I am exempt from the Contractor's License Law for the following reason: ( ) 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). ( ) I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business & Professionals Code). ( ) I 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 for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ( ) I have and will maintain 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 FXEMPT Policy No. (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-iffl should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions:; bate:.11l..!/ "-i 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 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 .4to the building construction, and hereby authorize representatives of this City to enter upon the above-mentioned property for inspection purposes. Signature (OwnedAgent)%r.� Dae�> BUILDING PERMIT PERMIT# DATE VALUATION LOT 0004-346 .i* TACT. ` 04l. Q/20C 52.402-50 M30,131 lI'1, JOB SITE ADDRESS 77^s AvviZ7i IaEJSV'.s:'iDly' APN 77,E-�D /rB^�302 OWNER CONTRACTOR / DESIGNER ENGINEER Y C:SACtYF.U✓ATAURI�,MLATION &P tAYTfRMi:C0S8ARVaT0t 45.871 CiMONq'l E 51.539A1r. MAMARi" 4E.. D.010 CA 92,201 I -k QYJmA,.- - ' CA 12253 0760)771-4.368 C'8T 3463 O USE OF PERMIT 0M4F1 A, 3St3TLD1HG FRANCIS HACK PA1IK Ca IF r5' ORN.KMD41TAI, IICON'[f rrm G7t' co C;OLUMMS !LF 8' BLOCK WALL AROUND 91,FCTRJ6L 1E.KV10`I? 4 ,Fr 6'WAL4CONCF.b"`aION &.COLUMNM, C'i> �f 6 Fr. WOOD" .FKNCE 8.00 LF �G 6 11 . 'JaA1,L 74.00 LF E,%7r 3 A' -r= 013;'. T 01r CONSERIT(,,"J° ON 2,402.50 M3Ml7" P + + SlUbMARY, CONSTRUCTION FLEE 101-000-418-000 -000 SM.00 KJB-TOTAI, CCt3+TL',V: UC" 011 AND P.LM CHECK $54.00 IZZ13 PRI3,PArD VMS $0.00 '.1`S3I'IS4'..1:':F,hMT.r 11TXS DUFMOW $54.00 R .r' RECEIPT DATE i BY DAZq FIN INSPECT R OF INSPECTION RECORD OPERATION j 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 Wali Firewall Exterior Lath Drywall - Int. Lath Final Final POOLS - SPAS BLOCKWALL APPROVALS steel Set Backs Electric Bond Footings Main Drain BA rd 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 Pod[ 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 Myn Service Se Panels Ext9rior Receptacles Smoke Detectors Temp. Use of Power Final Utility Notice (Perm) ci& 0 A-, OF Tt To: Greg Butler, Building & Safety Manager To . CDD.y�Z9�o 3 _ From: , Planning Due date: Status: Building Plans Approval (this is an approval,to issue a Building Permit) The Community Development Department has reviewe I the Building Plans for the following projec�;o✓ i� w;7x co%-„� sv✓� Description:.6 Address or general location: 7 %- APN and/or legal description: j The Community Development Department finds that: . x O ...these Building Plans do not require Community Development Department approval. ..these Building Plans are approved by the'Community Development Department. i Planning Date t— T.O.K I...,_\c ' m v 6.0 D ATO N �n 4+1 1 b• -On =4' 1 LAL �-- • PER • ,4,pd Nlb r- I El 1:1 1:1 Fl. a s �v rvn.i :inv+i -7 II6 \� TOILE 1 see, L.I�yI� © 74 M I � LINE OP I I SOFFIT aeays� 113 I I CHILDI �..._ CARE C a+ i Oi'1 IIIca.F I 6 18 -L 5 I _ i HP PIE. V •• ,:• I i — 4 i -- p eAvG.4L1*+9- D. -�' - 3"4vG ,DIfM! 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