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9704-054 (SIGN)LICENSED CONTRACTOR DECLARATION I hereby affirm under penalty of .pe*'ury'that am licensed under provisions of Chapter 9 (commencing with Sectidn 7000)'of Division 3 of the Business and Professionals Code, and my License is in full force and effect. License,# Lic. Class Exp. Date 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: T ( ) 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. (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 to1he workers' compensa "on provis'6l of Section 3700 of the Labor Code, I s _��orthwith comply wi hose p visions. Date: Applica Warning: Failure to secureWo ker tnalties mpensation coverage is unlawful and shall subject an employer to cri in 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 prey for inspection purposes: Signature (Owner/Agent) Date f© PERMIT # BUILDING PERMIT CONTROL # 9704-054 ; 4 975 DATE 411W97 VALUATION 1,600 ,00 LOT TRACT JOB SITE ADDRESS 7�- 30 HW V 111 APN OWNER CONTRACTOR/DESIGNER/ENGINEER WELLS VAI,16 .J MWA_Irplerl, SIGNS 78-6301M"Y1.). i. d 1233r.. 1Z0N11. ,D q_, LA QI R`N'i"A. CA 9225_1 S"rc .'WrON CIA 95G08 i?1}i��9 9 t —29 I CRI N USE OF PERMIT Ali 8C, t 'v'i\E.iftl ltiJ.du 11,600.00 LS V ST11 AXED COST OF C. S11 .1ON 1.600.00 CONSTRUI "TKM $37.0 E,'s'4��C £ 4f}1-OOfl-x#2(1-Oi?Il S, 75 P1,A1gCIAEC4.F03 Cn Q S11.WiDTA1r CONI STRUr.;VON SND W AN C"HeC:K 180 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 Wall Insulation Condensate Lines ,,Party Wall Firewall Exterior Lath Drywall - Int. Lath Final Final — BLOCKWALL APP OVALS 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: �,�t�H. f G _ i3,� �— C l �j— r 7 State of California '-; CAffain y CONTRACTORS STATE LICENSE BOARD nam •• m ACTIVE LICENSE liaueNumber 2 9 9 15 b Eo CORP . MINA -TREE SIGNS AGES INCORPORATED DBA MS( Company Name-: (as shot• CIO C45 C61/D42 Mina -Tree Signs, Inc_ 08/31 /97 Address:--_-P.0.—Box f Phone # _209-941_2921 Contractors Lic. No. 290,756 _�..._ Class.- C61,C)t;, INFO FOR CITY LICENSES ! X Sole Partnership Cor Owner/Officer x. L.—Minatre Address —__ Stockton,CA 95212 —_i— Phone # 209-941_2921 Work Comp# WP 9356527102 t Fed ID# 94-172_4960 State ID# _ 190_0299-7------_ - Soc Sec# _^557.420892^ --- Dr Lie# B1753049_—___. -__TJ -- Carrier Fremont Comp'. ins. The following named agents are hereby granted permission to Apply for, execute, receive & perform all acts neces ary to obtain building permits, city licenses etc. from cit; & county agencies. r Permission is to remain in force until written notice of can- cellation is given. AGENT; Lauri's Permit�Service 3320 E CHAPMAN AVE #281 ORANGE CA. 92669 This permission is granted -by: ----------------- SIGNATORS: Lauri Burke, Squeak Kossnar TITLE: -_-_-----_-----__.___ DATE: ,05,,96 07:59 %1209 942 2132 ORD rhe-r-ty and.Company >- Box 7369 !kton, CA 95267 1) 957-6800 :-`area Signs Box 8406 ktan,, CA 95208-0406 III S I A Cl�."e THIS ICERTIPICATE 13 ISSUE AS A MATTER OF INFORW-TION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE pOUCIES SPLOW. COMPANIE.S AFFORD_ !NG COVERAGIC . COMPANY ...... A CareAmerida r^""'-Sation COMPANY COMPANY 0M Y 1 TO CEAT Fy TjqAT r BEEN ISSUED ,_jE pCUr F INSURANCE LISTED BELOW HAVE ES THE POLICY PERIOD -nON OF ANY CONTRACT OR OTHER DOCUMIWr wl-,ri Ae3PECT TO WHICH THIS TtO. NOTWIlliSTANDiNG ANY REOUIREMENT, TERM OR CONI)i TO THE INSURED NAMED ABOVE FOR KATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED By THE POLICIES DESCRIBED HEREIN IS ssVBJECT TO ALL THIF TER.VS, 'I'? 11 CONDITIONS OF SUCH POLICIES, ITS SHOWN MAY HAV BE REDUCED Y PAID CLAIMS. LIMITS I "%'E OF IN SU FAN C E POLICY NUMBER PoLbcv vwMT POLICY III sl_ lin"Fury DNCVDN�) DATE (§QV0D!M LwOs '(QUAL GEN15-A-1 LMILrrY• OkGGREGArr wt�F F7 OCCUR , 211_00UM CON7RACTORt NCT I PERSONAL & ADV !NJURY EACH OCCURRENCE 3 KED EXP (Any gne w !son) 1Y A"o COMBINED SINOLC-IT I. Q`et%h_:o AUTC3 LIM `E'.!JLFO ALITM BOO ,LY"RY (Per P61w) AUTUS AUTOS BODILY INJURY (Pat A"enO Y ALTO Lt. Fl,rRkj II ;�.Twkbl uMMro.nw Z COMMSAMN AND Imp I• TTY 0000320101 X FyNCLc I ,TCv7nvE RX . 'L 07/01/96107/01/971 IF OPERA-,rcHs,l,, toc",,,—,,-, ,—,,,, ' seats C ts: contractors licezise #299756 ect to 10 -Day Notice -Of -Catcellation for Kon -P :tors State License Board �x 26000 :rj-to, CA .95826 PROPERTY DAMAGE $ ... ..... .. AUTO ONLY. EA ACCIDENT OTH1Z.li THAN AUTO ON�Y, FACH Ar-CljRRE AGGREGArr. i S EACH OCCURRENCE AGQAAFr.ATF. YrATIJ-.CTK Y Y, . IMI EL EACM A(;OIDEW tM CL DISEAM * 1`15UCY LIM11 EL 0 t Of Premium .. ......... . .7, SHOULD ANY OF THE ABOVE DESCRISID POLICIr ..... Z� . ... ... . 3 111. CANCEUC II "RATION DATA THEREOF, THE ISSUING CoMpANy WILL INDLPYOR TO ValL 30 - DAYS WArrTF.4 NOTICE TO THE CERTInCAM HOLDER NAIII To rXE Lr,'7 BUT FAURE To MA!L SUCH Honer, SMALL NPOSE NO oaugATK)N OR 04,11JUTY F ANY KIND UPON HE COMPANY, ITS ACIENTS OR , Lll,A�:7 '— - —& ...... . . 1 � — , TVF a 1. EC WMAUATION M PER AND AU AF TF x 8 EIVWUZ Y P" .*a JA t AN A t 4 ..L 4 // y *(,V c,-rI N k T�._�-•�. 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IT A 6lAW"EG FOR VOlRS P€RSAMhL'AEL IN COUKECTM MATH ✓4 lRQJECT EEOQ PLAR GIM FOR VDU Br MV1,4rREE War IMC LT {S NOT TQ U S?PCWM 10 ANYONE C1ITWlt f0uR 4RGARVATYOM. NOR IN R TO BE UM. REFFAX AD. MJ`1E12 qa Ex+nf►1EM aM AIlr F/&W401, 1 I I