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SFD (0301-110)LICENSED CONTRACTOR DECLARATION I!ivareby 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 674074 B WC Date (" '' 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 JJAJ'E FU1,!1) 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_f I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those p?ovisions. Date: - �� !� Applicant ' Warning: Failure to secure Workers' Compensation coverage is unlawful and shall subject an employer to criminal penalties and civil fines up to $100,000, in addition to the cost of compensation, damages as provided for in Section 3706 of the Labor Code, interest and attorney's fees. IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the conditions and restrictions set forth on his application, 1. Each person upon whose behalf this application is made & each person at whose request and for whose benefit work is performed under or pursuant to any permit issued as a result of this applicaton agrees to, & shall, indemnify & hold harmless the City of, La Quinta, its officers, agents and employees. 2. Any permit issued as'a result of this application becomes null and void if work is not commenced within 180 days from date of issuance of such permit, or cessation of work for 180 days will subject permit to cancellation. I certify that I have read this application and state that the above information is correct. I agree to comply with all City, and State laws relating to the building construction, and hereby authorize representatives of this City to enter upon the above-mentioned property for insr0tion purpos s. , 3 Signature (Owner/Agent).) !^ Date., BUILDING PERMIT PERMIT# DATE VALUATION .t4aj17.10 LOT 53 TRACT 2-9283 Ve / JOB SIT,,t ADDRESS J.Y.11in3�i3�4A1� .� NPN OWNER CONTRACTOR/DESIGNER/EN INEER PO BOX 1716 79495:RANCI101AQ1J�f7'�`aTaR . 1 CA 9225: I.,d�.��fI1I�TA CA 322 Q60Y7 71 1941 CBU# 2996 USE OF PERMIT sm - Lor 33, 1F'I.AN n, Puma ir3tln NOT I?vl~l.Orm f;Jl ocic WALLA P Ct:14 0PA OR DMEWAYAPMtai CM,'?5% 1t' iDUt;TIViq TO PLAN CfiWK FEE DUE TO A$ULTIPLA t6J'lf.t IXE OF S.AMS PLA14 TYPX CUSTOM CONSTRUCTION A91200 5F PORCH/d''.t TIO '23g,m S? 0AiRAIMU'G"ARPOR T 470.t1�1 OF Eff� � D COW Or, C'€J34'w" i7C'�']EON 24Q, 17,10 _ RrAwr N 90AW Any CONS`1' UC1' 01;1 U 01 -(M-418-000 $15133100 PLA 14 C'NEICX FEE 101-000-439-318 $3,71M MECKWCA111FER 101-000,1421.000 $130,30 fa.LEC'1 WC&L PTU101-000-A20.000 $169.3+4 PLUMBINO FRE, 101.000.419,:000 1175.73 STRO14 B MOTION FEE • REESID $34.01 GRADRIO &'EF, 101-000.4'23.000 WA 1?3V'V.OPFPs. MP.ACT "Ll' $2,4',35,00 ART ,IN PUBLIC PLAVES - .RESIT: 270-000-445-000 1100.20 a.; �... ...-�_...ffL "AOLp aflKV�. ' rylND Lq?�Ct� $4,185.01 173 "r'4111PAW + . ILSs $0.00 V/ RECEIPT DATE BY DATE INA INSPECT INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR '-' BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Underground Ducts Forms & Footings Ducts _ 2.6-W Slab Grade — Return Air Steel Combustion Air Roof Deck Exhaust Fans 0. K. to Wrap F.A.U. Framing _ 2 - y 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 Plbg. Test Final I Gas Piping PLUMBING APPROVALS Gas Test Electric Final Waste Lines © v Heater Final Water Piping_ `�ZZ' ;/ Plumbing Final Plumbing Top Out % Equipment Enclosure Shower Pans O.K. for Finish Plaster Sewer Lateral ni Pool Cover Sewer Connection Encapsulation Gas Piping Gas Test / Appliances Final COMMENTS: Final Utility Notice �p ILL— (Gas) . ELECTRICAL APPROVALS Temp. Power Pole Underground Conduit Rough Wiring _ TA ` z 1 Low Voltage Wiring Fixtures Main Service Sub Panels _ Exterior Receptacles G.F.I. Smoke Detectors Temp. Use of Power Final` /> Utility Notice (Penn)