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0305-076 (PAT)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. Clasr,� Exp. Date .'�.1 0484 L° Date r Signature of Contract,` A, D. OWNER -BUILDER DECkA3ATION 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 T,A3'F� N'UAIt� Policy No. 2Zy-34�9�;tOti4 ' (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' compensation provisjcns of Section 3700 of the Labor Code, I shall forthwith comply with those provisions. t /j Dated Applicant d � ^ Warning: Failure to secure Workers' Compensation coverage is unlawful and shall subject an employer to Crim .yal pAalties and civil fines up to $100,000, in' addition to the cost of compensatierl,/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 inspection pU rposes. ( V Signature (Owner/Agent) / �- � Date BUILDING PERMIT PERMIT# DATE VALUATION LOT 00b76 TRACT JOB SITE1r ADDRESS 44-735 OINMUCf�i,��e 0 AVEMOR APN OWNER CONTRACTOR/DESIGNER/EN (NEER CAWDIC•E 2ICiORMINAZ, -.P1 I.. 'TIES GfJN'l.R.z:7G'TiCN• 44 -7 3d 1YSON dIORLat 0 AMMME ROAD LA, QUIl+1'YA CA 92253' '1'HOLTSAK0 PALM Chi 92'016 (76P)275-6017.. C BUJ.- :3106 USE OF PERMIT MIX) TWO 1AT T1 C E ALINAWidOD t7ATIO C:C)1/ ERS(43b N F). ' PORf:HIPA1110 436.00 8F E91M ATED COST 0X' CC)XS`rWC.T1Q1T r yCtQs ,€3ti Yl.�,kN aftY_1K f+EF,. X101'-000459-318 %skso CG1 stltucTi014 RIE A 1 i.-i9�0-�1#aS • t3(J $90:60 Wf RON0MOTION ritZ - MRSID 101-000-241-000 • ' �,6S FMY. 0 7 2003 CITY OF LA fdUINTA FINANCE DEPT. i 3l'TB-T0 AL.0"0WM?, ,&i•CM0W AND -PT M CkWX $149.11 MISS PKE-PAM1i'F.1LS : x©,00 TOTNT. PERMIT ..S DTIN, NOW . $3.49.1.1 RECEIPT DATE BY f DATE FINALED INSPECTOR 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 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 Wall Firewall Exterior hath Drywall - Int. Lath u�oo zoo Final Final !4 a BLOCF IM Alf 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: