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SFD (9609-075)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 89622 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 thework, and the structure is not 'intended o—r offered for sale (Sec. 7044, Business & Professionals Code). ( ) I, as owner of the property, am exclusively-65racting with licensed contractors to construct the project (Sec: 7044, Business & Professionals Code). �.�-- O 1 am.exemp L " er Section B&P.C. for t ig'"reason . Date �� �" 7 . Signature of 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. (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 prov+sl ns of Section 3700 of the Labor Code,11s..all! .o • , 't `comply with those r • visionse Date: ApplicantWarniFailure 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 f P ni spection purposes. /✓Si' ature' (Owner/Agent) _ �-- "� Date 1 f BUILDING PERMIT PERMIT# CONTROL# 9417.5 4 0 01 DATE 9/61% VALUATION �'� 'LOT TRACT JOB SITE -74-666 A ' 1fi.itA. IiAkQ''% JA APN 1640-9,17-IM11 ADDRESS OWNER CONTRACTOR / DESIGNER / ENGINEER CARL ,,ci(,iERK-lt(1 MOJAVE BUILDERS 73-2413 WiLLO SI' 51-M AVENI1: A HERRER.ti PALM I; HSERT ("A 92'7410 LA QUINi-A CA 92253 346-4805 Xut-0148 CBL4 USE OF PERMIT SINi 11.t PAiVH0 I.)WE RANG f?WM,ft C*0NTt Af.*J'0R CHANGE NEW NO Mil's I'i ItArtiT RE -ISSUED FOR PEAtAiITS 156M. :+f•"tl. 1566 HLK WALL, IM15 IIcXnl, AN11 SPA- F-STINIATED Ujk i3>r' CONST R1Ii:'iION ci.4fti PERMIT FFE SUMMARY SU13-'10FAL CONS 1t1.IMION AND PLAN C11UCK, $0.00 LESS PRE. -PAID FEES ZU.OQ TMAI, PERMIT I/`il',FS DUE NOW so."o ' RECEIPT DATE BY 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 Wali Insulation Condensate Lines Party Wall Firewall Exterior Lath Drywall - Int. Lath Final Final BLOCKWALL APPROVALS POOLS - SPAS steel Set Backs Electric Bond Footings Main Drain Bond Beam Approval to Cover Equipment Location Under r / nderground PI . 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 5151p / i lilt v Final Final 9 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: h l%(i� ` a I