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BLDG (0101-085)53800 Avenida Martinez 0101-085 LICENSED CONTRACTOR DECLARATION I hereby affirm under penalty 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 Dater !n ­Z'd Signature of Contracto " d -_Yo r,N- 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). A () I am exempt, under Section B&P.C.tfor 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 Policy No. 0',ATST FUND (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' compe6sation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions. , Date: A 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 to the building construction, and hereby authorize representatives of this City to enter upon the above-mentioned pr"operty for inspection purposes. Signature (Owner/Agen y _ 4 _ ?' Date BUILDING PERMIT PERMIT# DATE VALUATION LOT TRACTkb) - 'n'i' ' JOB SITZ` j APN ADDRESS OWNER CONTRACTOR / DESIGNER / EN (NEER Ct''ft 9.WIL COM7111'YCSTON LA QUM'F'A. CA 92:253 LAQUINTA CA 9122:33 (760)564-4604 CMM, 2 261 USE OF PERMIT t 150 i,.,F' 311 GM)M `hil'.ALY., (PURT 3A YNO) f: JY STA.?ti'5:1. 110 ONLY ; r 3 PT, WALL ISM LF 1 t "a'i;lB-'!<''WAL CONSTRfSM I:ON ASD FLAN CIM -5L $63.00. LESM PRE -PAID F709 V401 I'4y.t.t L Y13W. K ' FENS ]3 i E , NOW WIM RECEIPT DATEaN ti , DATE FINALED INSPECTOR INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE TINSPECTOR 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 Wail Insulation Condensate Lines Party Wall Firewall Exterior Lath Drywall - Int. Lath Final Final BLOCKWALL APPROVALS_ POOLS - SPAS Steel Set Backs Footings l Electric Electric Bond Main Drain Bond Beam /_( .v s' Approval to Cover Equipment Location Underground Electric Final _ Q -© Underground Plbg. Test 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: CITY OF LA QUINTA BUILDING & SAFETY DEPT. APPROVED FOR CONSTRUCTION DA q u— q BY APPROVED BY PLANNING DEPARTMENT BY w DATE EXHIBIT CASE NO. how%" &A"oltuft i I 1 I I ! • I . 4e I i i I I /E. i i f CITY OF LA QUINTA BUILDING & SAFETY DEPT. APPROVED FOR CONSTRUCTION DA q u— q BY APPROVED BY PLANNING DEPARTMENT BY w DATE EXHIBIT CASE NO. how%" &A"oltuft M6.