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0302-209 (RR)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 5.55470 C'39 B 01/31/2c D to a :%; ;i46 `' Signature of Contractor -F.b ." s•= ..-" .• i 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.slple 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 FX.AMPT 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 provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions. �^/1 Date:,A int 6 �� Applicant 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 inspection purposes. Signature (Own er/Agent)/�—�Zt--,--.- ='f -- Date •�'r PERMIT # BUILDING PE VIT DATE + .:+ VALUATION LOT 01r)2C20 TRACT 02MfM8�d3t? �Pb JOB SITE APN ADDRESS 52-285 AVEMM RUBIO OWNER CONTRACTOR/DESIGNER/ENGINEER CHRM"C7fN R ROUISWEU, TUNSIX, Y C0,1IS'ile13MON CC?;la,I:i'ANY 52-285 AVM. DA RUBIO W;,i a 17 0 ENURA .) AVE J"rk CA 92253 1= 10 CA 92.201 (760)776.03.73 CBIA 2201 USE OF PERMIT 10MMAL 3t3Ia: ]NO R ,.RDOFWITH CLASS,A. COVIPOSITION SH11--401.,NS REDIROOF 4,000,00 L0 ESTIMA11M CWT CDS' CONSTRUCTION CTION pjmmr ME I�IUAG"Roti REROOF FIV 1-01-M10-418-000 -810-418-©00 $30,00 FEB 2 6 1003' CBTY O? Lie, C1UfFdYA SUB -71 Cr °AL CUN=UC 7'1014 AND i?L,F K CFMCK L IS PPX_� °,tom 117EF55 JRECEIPT DAT O^ �,,�� BY� DATE FINALED I INSPECTOR 4,00009 $0.00 INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Underground Ducts Forms & Footings Ducts Slab Grade Return Air Steel Combustion Air Roof Deck Exhaust Fans O.K to Wrap F.A.U. Framing Compressor Insulation Vents Fireplace P.L. Grills Fireplace T.O. Fans & Controls Party Wall Insulation Condensate Lines Party Wall Firewall Exterior Lath Dryvwa11- Int. Lath Final Final POOLS - SPAS BLOCKWALL APPROVALS steel Set Backs Electric Bond .Footings Main Drain Bond Beam Approval to Cover • Equipment Location Underground Electric Underground Plbg. Test Ftaal Gas Piping PLUMBING APPROVALS i, Vllaste Lines Gas Test Electric Final Heater Final Water Piping Plumbing Final Plumbing Top Out Equipment Enclosure Shower Pans O.K. for Finish Plaster Sewer Lateral Pool Cover Sewer Connection Encapsulation Gas Piping (Oas Test Appliances " Final COMMENTS: _ R. Final Utility Notice (Gas) ELECTRICAL APPROVALS Temp. Power Pole Underground Conduit Rough Wiring Low Voltage Wiring Fixtures Main Service Sub Panels Exterior Receptacles G.F.I. Smoke Detectors Temp. Use of Power - Final Utility Notice (Perm) Page No. of State tic.55547o HENSLEY.CONSTRUCTION CO. 83170 EMERAMAVENUE INDIO CALIFORNIA 92201. (760).342450 ' 6 V.M. (766).,776-0373. PROPOSAL SUBMITTED TO 6 . l 1 ; RlffSl . ' fiATE STREET B "WE �� CJ CITY ST AND ZIP ODE JOB LOCATION' f � t ARCHITECT DATE bF`PLANS JOB PRONE i St fr>1pm hereby to furnish material and labor — complete in accordance..with above- specifications. for the sum of: ayment to be made as follows: dollars ($ ) . 'Alk material is guaranteed to tie as specified. All work to be compiatee in a•vwramanlike' /j maned► "cording to standard praetces. Any Alteration or devZation fqm; all,0* specific&:. . Authortsed.y t tions invalvina extra Costs will be exec ited.only upon written orders, and will'Decome sn •SlgriAture extra i:narse over arid armee the edtnnate. All atirarfinentsconiirylerrt upon strike►• accidents or delays beyond our control. Owner to Carry fire. 'tornado and o"at necessary insurance. • '. - Note: This,proposail maybe Olw workers are fully covered by workmen's CompenaaHan rnsurarice withdrawn by us if riouaceepted within days. Araptmir at f ravotaL —The aoove prices, specifications and conditions -are satisfactory and are hereby acct pted...You are authonied Signature to do the work as specified. Payment will tie made as ouilined above. Date of Acceptance. Signature.