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0112-154 (BLCK)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 595754 x'31 C9 (36!30!21( Date { a - �� r� t Signature of Contractor n 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. (�V) 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 STATE FUND Policy No. 229-00 U)J!T 0011M i (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 tq the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the L''abor _ Code, I shall forthwith comply with1hose provisions. Date:! Applicant— ,Warning: Failure to secure Workers' Compensation coverage is unla I and shall subject an employer to criminal penalties and civil fines up to $100;000, in©E addition to the cost of compensation, damages as provided for in Sec�3406 of the Labor Code, interest and attorney's fees. L�:_ IMPORTANT Application is hereby made to the Director of Building anti Safety for a permit subject to the conditions and restrictions set forth of n is 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 erhployees. 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. --R Signature (Owner/Agent)_ %l "'� - �'ti Date -u aw PERMIT # BUILDING PERMIT DATE VALUATION -. s3 974 fw1 LOT TRACT tN�V+IVNlJ JOB SITE ADDRESS 53-27A)AVERMARUM0 APN y OWNER CONTRACTOR / DESIGNER / ENGINEER Ph CAZ1`tlLt..O_, PAZ COMMUC.'T.(ON CO 53.220 AV".ENS.1'JARUBIO 5.993 AVOMk]1 L)OZA LAAO Q(:%12 A CA 92253 LA C4E.Wrm CA 922155 iCi60)564-3023 r-PALY 55317 USE OF PERMIT 1501,. N'.COhl ata 3VALL 3.�* RLtTf,1'NJ N4 6' CARDkrN; 141..X4' 6 FT. WhIA, 140.00 1.P 4 FT. WALlr 14.00 Lf+' Eslxuakf a) COM OF COMY1rF?I,7MON :),974,00 CONSTRUCTION V_.� 101-000--$1 8" 000 $6100 L11,� C 21 2(101 _ MM-7"xrAL C0k°1tCa'C 10AUl' O PLA,W C I-MCK $c,Ti.to 'f LWO fln-r.t M x SfJM TOTAL PIMM. T'V7013 DUE .NO'f/0' RECEIPT DIE BY / C D�V FI ED C�/1 INSPECTfJ INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs i Underground Ducts Forms & Footings ,,' Ducts Slab Grade Return Air Steel Combustion Air Roof Deck Exhaust Fans O.K to Wrap ;. F.A.U. Framing f' Compressor Insulation Vents Fireplace P.L. 3: Grills Fireplace T.O. ± Fans & Controls Party Wall Insulation Condensate Lines Party Wall Firewall 11 Exterior Lath ' Drywall - Int. Lath Final Final BLOCKWALL APPROVALS POOLS - SPAS Steel Set Backs Electric Bond Footings 2 Main Drain Bond Beam / Approval to Cover Equipment Location Underground Electric _ Final �j/j� Underground Plbg. Test 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 i 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 1 Temp. Use of Power i Final Utility Notice (Perm) COMMENTS: