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0311-095 (RR)LICENSED CONTRACTOR DECLARATION I hereby affirm under penalty of perjury that,l 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 ivyC)639 p Yy� Date—q-_" 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). O 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 . STATSFUND - Policy No. • 0444.00209,14 (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 Section 3700 of the Labor Code, I shall forthwith comply with„those provisions. _�--- '"Date c Applicant X) // rt ,I 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 ins ection purpose Signature (Owner/Agent) �At-�`� _� Date' PERMIT # BUILDING PERMIT e . $11-49s� VALUATION LOT TRACT DATE,7/ Wmw / JOB SITE APN ADDRESS • 9.271 a TGAWA.Y11I w OWNER t CONTRACTOR/DESIGNER/EN (NEER M&I;1.PR0.9 M'TY- HAGEtVN1 I1,C MOM= MMZPFi3FX 12,55 $1.110I3 FsUIRF I) .Z.STK 285 441 C(?AOJ%EZCJA[.-W_AY SAN DIL'0 CA 92130 LA I'.M CA :90631 (562)690.9559 CEU 1871 - USE OF PERMIT (3LMMAL J3i3=ING ROOF EQU9;e►MENT SCRFZN CCiAfSt WUCTIOM, DEL -TA -12.- DELT.A.11 MISTONIS FOR RRAR & I;1 DWO & ��iD RA:f.0 VALUATION 51009.00 LS EST.➢4ATUD (.109f 01r C'd3HMUCI'dON x'E,R1VI I BTE Sf>CTi+r[NI:ARY IPI,tiV GI” MCK FEE 101.000-439-318 C014STRUC w %CSN Ft'E'M 101-000-418-000 STR.ONO MOTION FEE - COMM 100.000-241.000 Fra 09 2004 CIOF LA QUINTA FINANCE DEPT - MM -TOTAL COHO :R.1TM09 AND V11..Ps1vY C.TMCK $119.95 L aN PRT3•P�AID.'F $0100 TOTAL PERMt'%' MeS DUN NOW $119.65 RECEIPT DATE -BY DATE FI ED ' INSPECTID INSP.ECTIONAECORD OPEWT6N' Y{ ,E 5^: DATE INSPECTOR OPERATION F DATE INSPECTOR BUILQING 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 Lath Drywall - Int. Lath c D Final Final 0 j BLOCKWALL A PhOVAa 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 Pars 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: / �'Q'� %7s*df�ldytj�b0 f'� ✓� • " ~ lj oYf,:1+II �tpv, a,rs A4,V To IdL X A X V1✓i:)"Go e✓ Big5-DCity C- of La uinta Q Building SE Safety Division Permit # P-0- Box 1504, 78-495 Calle Tampico La Quinta, CA 92253 - (760) 777-7012 011- Building Permit Application and Tracking Sheet Project Address: ,0 4 Owners Name: A. P. Number: Address: Legal' Description: 1CCity. ST, Zip: { Contractor. % ;Telephone:. . _ ••.,. - a: ',�; Address: XProject Description: City, ST, Zip: Telephone: f A•• �' State Lic. # : City Lic. #: Aich., Engr., Dcsignet: �-�• �� - �`� f CC��y��^ Address: City. ST, Zip: 12--C�5 6-70 Telephone: •. _,�,,; Construction Type:' /l1 Occupancy: State Lic. #: �i'"ZZ l`.CJz.:- Project type (circle one): New Add'nEAI�terRepairDemo Name of Contact Person: �lNfi vaVA, / Sq. FL: # Stories: Units: Telephone # of Contact Person: 91we imated Value of Project: S d60 • °G APPLICANT: DO NOT WRITE BELOW THIS LINE p Submittal Req'd Rec'd TRACKING PERMIT FEES �p Plan Sets Plan Checksubmitted 11 o Item Plan Check Deposit Amount Structural Cala. Reviewed, ready for corrections Truss Cala. Called Contact Person Plan Check Balance o Energy Cales. Plans picked up Construction Flood plain plan Plans resubmitted Mechanical Grading plan 21' Review, ready for eorrectio- issue !//f 1 Electrical Subeontactor List Called Contact Person Q } 44 Plumbing Grant Deed Planspicked up S.NI.l. C H.O.A. Approval Plans resubmitted Grading IN HOUSE:- '"' Review, ready for co rrectionsrssue Developer Impact Fee Planning Approval Called Contact Person A.1.P.P. Pub. Wks. Appr Date of permit issue g School Fees scuts �ws al? � 1. • /�� !S P Total Permit Fees X Bin # Permit # Project Address: 2-71 11W City of La Quinta Building ar Safety Division P.O. Box 1504, 78-495 Calle Tampico La Quinta, CA 92253 - (760) 777-7012 Building Permit Application and Tracking Sheet 5 Zc If% 4 Owner's Name: 44 A. P. Number: AAddress: Legal Description: i(City. ST, Zip: Contractor:ft&V�Al t FTelephonc: Address: "yProject Description: City, ST, Zip: Ego 6 5&7cs Telephone: X17 - State Lic. # Arch., Engr., Designer: G City Lic. —IM DbA 7r Address: City, ST, Zip: CA Telephonc(p,2) 31 State Lic. #: a 2C9110 Name of Contact Person: . . . . . . . . . . . . . . Construction Type: 40 Occupancy: Project type (circle one): New Add'n/Al er) Repair X Sq. Ft.: # Stories: # Units: Demo Telephone # of Contact Person: XEstima'ted Value of Project: APPLICANT: DO NOT WRITE BELOW THIS LINE # Submittal Req'd Rec'd TRACKING PERMIT FEES Plan Sets Plan Check submitted Item Amount Structural'C21CS. Reviewed, ready for corrections 911Q Plan Check Deposit Truss CaIcs. Called Contact Person Plan Check Balance Energy Cales. Plans picked up Construction Flood plain plan Plans resubmitted Mechanical Grading Plan 2" Review, ready for corrections/issue Electrical Subcont2ctor List Called Contact Person Plumbing Grant Deed Plans picked up S.M.I. H.O.A. Approval Plans resubmitted Grading IN HOUSE:- Review, readv for correctionsrissue Developer Impact Fee Planning Approval Called Contact Person A.I.P.P. Pub. Wks. Appr Date of permit issue School Fees Total Permit Fees *Ike AAA.IC44- qI-se-103 2A-Z&,Z,,b,