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0008-257 (RPL)LICENSED CONTRACTOR DECLARATION I herebyaffirm, 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 % i �8, / B TIAZ 1 /2( •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: ( ) 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).`. V, ( ) 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. FITATE FUND ' 229-00 UNIT 0004483 (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 kny person in any manner so as to become subject to the workers' compensation laws of California;, nd agree that if I should become subject,to the workers' compensation=revisions of Section 3700 of the Labor Code'l shall forth ith comply w51rhose provisions. afe '�f of Applica&''� 6L/ Z 11"*' Warning: Failure to secure Workers' Compensation coverage is unlawful and shall subject an employer to criminalpenaltles and civil fines up to $100,000, in addition to the cost of compensation ,;amages as provided for in Section 3706 of the Labor Code, interest and attorney's fees. IMPORTANT Appy atio�hereby made to the Director of Building and Safety for aipermit,subject to the conditions and restrictions set forth on his a 0rication. 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�forrin pectio• nn purposes. Sj • nature (Owner/;4geDate BUILDING PERMIT PERMIT# DATE �' VALUATION LOT 0"_2S'7 TRACT JOB SITE t APN ADDRESS I.3 -ice AV'.�N1DA R'EM10 _ OWNER CONTRACTOR / DESIGNER / EN (NEER STARL ORT 1 AC�}k%P_XT WC WILLTAM RLfSS)rj L R013M 51-370 AVY"A B}M1t P3, 56900 JAMON S'T LA QL,IIN=CA CA 92253 1�"'C�. AAL CA 92274 (760)399.1200 C'BL# 1954 .r USE OF PERMIT TOOL ANDIOR SPA POOL ONLY NO I3FATER, - ALA t1aI MA.RRIERS ;11.1.ALL 8E IN PLACE AX PR&PL.A:iT R INSPECTION, POOL EQUIPMENT .ENCLOSURE NO, INCLLII&D IN THIS PERIBIT. POOL ANDIOR SPA 5,0moo W1, c T18TMA131) COW OF Cl NYME 7CT OM $,930t)w PLAN CI°IF? K FEE . ] 01.000•'439.318 CONS!'R.t1CTION FF 101-0t3C1 1£t-t10fl $99.00 ELECTRICAL FEE -- POOL. 101-000-420-000 $45.00 PLUMBINO FX9 •• POOL 101-0004M000 $27.00 'A SM=:i`O`FAL C014M1RUC.ROM AND PLAW CiWICK. $2,15.35 '� F-.�8 PRE.P.41D MS $0.00 u; 11 %% RECEIPT DA E ]� By� DATE FINALED r INSPECTOR vV INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs L. - Underground Ducts Forms & Footings 1 Ducts Slab Grade I° Return Air Steel 1, Combustion Air Roof Deck 1 Exhaust Fans O.K. to Wrap la F.A.U. Framing ;'. Compressor Insulation Vents Fireplace P.L. ,, Grills Fireplace T.O. 4 Fans & Controls Party Wall insulation Condensate Lines Party Wall Firewall Exterior Lath Drywall - Int. Lath I: 11 1L Final Final BLOCKWALL APPROVALS POOLS - SPAS Steel Set Backs Electric Bond Footings Main Drain Bond Beam It Approval to Cover Id Equipment Location p Underground Electric I Underground Plbg. Test Final I Gas Piping PLUMBING APPROVALS 1! Gas Test Electric Final Waste Lines b Heater Final Water Piping I! Plumbing Final Plumbing Top Out I? Equipment Enclosure Shower Pans ld O.K. for Finish Plaster Sewer Lateral II Pool Cover Sewer Connection 1, Encapsulation Gas Piping lu Gas Test Appliances I' It Final 13 Final }r Utility Notice (Gas)I+ ELECTRICAL APPROVALS ]f Temp. Power Pole I6 Underground Conduit Rough Wiring 1i Low Voltage Wiring Fixtures 1C Main Service 11 Sub Panels }1 Exterior Receptacles G.F.I. I! Smoke Detectors 1. Temp. Use of Powe- Ii I} Final rf Utility Notice (Perm) COMMENTS: