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9812-029 (AR)0 U N_ W O c) r1L d rZ o Z r - CC) O O JV� ~a N Z M LO N 0 N U °) a_Q Cc r -0 X W 0-1-1 mVU O MLO Z_ ao r, - 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 ,)14 i gts P3 � X13,11 3 Date/a- �I - Ignature 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 Policy No. WILVEN, SAGLE INS,. N71= 544068-00 (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 provisions of Sect on of the Labor Code, I shall forthwith comply with tho�provi i ns. Date: lL f�,�Plicant Warning: Failure to secure Workers' Compensation4overage 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 p�specctti n purposes. Signature (Owner/Agent). /�.1: f !r-^ Date BUILDING PERMIT PERMIT# r DATE VALUATION 37,564.60 LOT TRACT 27".) JOB SITE ADDRESS 79,-091SmEN PLACE. APN 604-374-016 16 OWNER CONTRACTOR/DESIGNER/ENGINEER ? 0.1pTrUIRyCp WEL wAfry11111 S 4J/MVpM rEiTiR M/MrEYL -S :I„s35 SO. "li" grurr, sru. h200 1535 SO. `D" S'i'N EEE, SI -E.,0200 SANNt .BE:[WAN.i INO C.A. 92409 SAN 13ERNARDINO CA, p924�W 20 USE OF PERMIT RESA17.EMIAL ADM 11014 C1tA14GE DEl ki-I' PLAN 3 TO PLAN 3X D1:7111NG L"ONSTRUC'i`1014 (. DIDS 2193Y.) PL NN C'HEC'K FEE ti EVUCHO 75?:o FC. At MU1.'t IPLI-:.18 UANIC.1? 01� .S AME PL X9 TY PE. TRACT CONS"a:1 ICTION 218.00 Sr 1:1157 iM.TED COST OF CQN3`' *RUC.fION' 7,564.69 CON51'1btfM3 10N FEE [©.1-000-418- ,'0-46.tX) PT, AN ICT ct?C K r.01- 101-ft(A -439-3 i R $7 414 7 i"-i11VINf1 AI..FI 1 10t-�'t)0-"2.1-Otto 1Ci.5tr ELL:CTIO.0 AI. FIX.. 101-000-420-000 $3.27 h;'ikrJ�lO MOT 10N FE - - R,b"00 101.-4) -2 41-CJi)t) 5.76 1 NPR t $Tild.1 JI `I" 11.0 r FIR-: `° 3 54100-441-342 S 170 Zai St 19-T(TrAj, !',:i,:tNFIRUC."Pid)1+3AND MAN C R C K LESS PRE -RAID FEES $0.00 !'OTAt.. ,PC;14t rF FEW$ ` I C' 1\1O;R1' $22.3.77 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 peck 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 Lath Drywall - Int. Lath Final Final BLOCKWALL APPROVALS POOLS - SPAS steel Set Backs Electric Bond Footings Main Drain Bond Seam 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 Fbdures Main Service Sub Panels Exterior Receptacles G.F.I. Smoke Detectors Temp. Use of Power Final Utility Notice (Perm) COMMENTS: