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SFD (0301-028)LICENSED CONTRACTOR DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of ' H, Chapter 9 (commencing with Section. 7000) of Division'3 of the Business and c,4 W Professionals Code, and my License is in full force and effect. �j License # Lic. Class Exp. Date Lu*��A t 674674 B 111 Fr' 71J1C�r' . Z �ate F `-7s Signature of Contractor oOCID - r V'0' . OWNER -BUILDER DECLARATION W .LLI hereby affirm under penalty of perjury that I am exempt from the Contractor's ~ a License Law for the following reason: Z_ (') 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. 7.044, Business & Professionals Code): , M O I,am exempt.under Section B&P.C: for this reason N Date '- Signature of Owner O.C\I CJ'... WORKER'S COMPENSATION DECLARATION D- — �• C I hereby affirm under penalty of perjury one of the following declarations: PZ .0 O 1 have, and will maintain a certificate of consent to self -insure for workers' K:LLj IL compensation, as provided. for by Section 3700 of the Labor Code, for the 01. 44J JQ performance of the work for which this permit is issued. Q, I, '( ,,have and will maintain workers' compensation insurance, as required by U Q Section 3700 of the Labor Code, for the performance of the work for which this i L H permit. is issued.. My workers' compensation ' insurance carrier & policy no. are: z Camera'f.`l•1<!)�"l?°": Policy No.��7�� 211 ` J (This section need not be completed if the permit valuation is for $100.00 or less). (-) 1 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 a r 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.,,". t Date: r.! % Applicant_ Warning: Failure to secure Workers'.Compensation coverage is unlawful and Shall subject an employer to criminal penalties and civil fines up to $100,000, in addition to the cost of compensation, damages as provided for in Section 3706 of the Labor Code, interest and attorney's fees. af IMPORTANT, Application is hereby made to the Director of Building and Safety for a permit subject to the conditions and restrictions 'set forth .on his application. 1. Each person upon whose behalf this application is made & each person at whose request and for whose benefit work is performed under or pu'rsu any permit issued as a result of this applicaton agrees to, & shall, inde & hold harmless the City of La Quinta, its officers, agents and emplo e�s 7. 2. Any permit issued as a result of this application becomes null and v 'ci'iiw work is not commenced within 180 days from date of issuance of �cf� permit, or cessation of;work for 180 days will subject permit to cancell ion I certify that I have read this:application and state that the above informati n. is • correct I agree twddmply with all City, and.State laws relating to the bui in :construction and'herebyiyauthoriie representatives of this City to enter upon ` 4the above mentioned property for'inspection purposes r,.Signature (Owner/Agenntj �- i - YDate` °* BUILDING PERMIT PERMT# �;� ��Md DATE VALUATION LOT TRACTJOB SITE ADDRESS �9 Tf 3i�R"lf�.�>•�u"� APN.�I-,J OWNER CONTRACTOR/DESIGNER/ENGINEER u .�� ���n � 1;� gn �?i �'�:? 7�41'd� •s�C) .�...�� ����`fi.£`i�i�, LA Q12INTT,A. 92253 LA. q'y TA CA. 922113. Q m,19,41 V1 -" . USE OF PERMIT �31t�ic��•L �,;�w3;1:�: Y' �'�ria�,.i.xk,T�i , SM, LjOT 4 , PLAN js..'�, +'P.i.:.IdJ'JJ13 DOES NOT INCLIME 9LOCN WALl.'s, ; lik:E3L.`EIITIQ 'FO M1j e,.TIPLE 15,StlANCE OF BAMS PL AkI T nvE ; PUSTCaM1";';i'iWAUC'iION 1101,924,00 OF FCRCidl210 r 215.00 S11 0A1MpiAVPdYIN OT) ry •h Enno-M MEW, COWNTRUMION 21401117.10 m' :alT ri?m sui'V "ARv (110 ARUC..i'30f'd TPLIF 101 -000 -418 -WO sl,1� p, f%i. hN i.•Hft':S Klilif,' � 101.000,439- 'fie'° '$B234 M1acwH"iC A1, FER 101-M-421400 41/30/60 1©3.000.4'19.0003 ST'ki,?Adt3.9i onoN' F-08,- u lr) 3 C1 X000-241-00 / GRAMM KZ 101-000-423-00,0 MAI ART 1W PUBLIC; .PLACES - k_ZSIE 270-000-44-5-000 (!QbT dtCT0R ,SME) MAR ;1,9� :K as 511 "i 011tJ� ?W*a ' 36 .x'. ' DUE. NOW JAN 2 2 2093 1, ' I 4 ITS' OF LA QUINA FINANCE [SEPT. .RECEIPT . , DATE- e`r' BY DATE FINAL -3 INSPEC ' T_ 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 ___5-zo- 3 Exhaust Fans O.K. to Wrap 51_/p 3 F.A.U. Framing 19 _// — Compressor Insulation S Vents Fireplace P.L. Grills Fireplace T.O. _ Fans & Controls Party Wall Insulation Condensate Lines Party Wall Firewall Exterior Lath Drywall - Int. Lath ` Final/3.3 LS BLOCKWALL APPROVALS Final 3 3 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 Waste Lines /� _ �d —� L5 Gas Test Electric Final Heater Final Water Piping Plumbing Final Plumbing Top Out Equipment Enclosure Shower Pans / O.K. for Finish Plaster Sewer Lateral Pool Cover Sewer Connection - 3 O - o Encapsulation Gas Piping Gas Test -- - Appliances Final Final Utility Notice (Gas) ELECTRICAL APPROVALS Temp. Power Pole Underground Conduit Rough Wiring _ /21 Low Voltage Wiring Fixtures Main Service Sub Panels Exterior Receptacles G.F.I. Smoke Detectors Temp. Use of Power Fi^i' Utility Notice (Perm) .% COMMENTS: