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0303-188 (RPL)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 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 -int ended or offered for sale (Sec. 7044, Business & Professionals Code)!.--`, . f ( j I, as owner ,of the property, am ex6lU§i4y cO67racv ,,wlin Iluensed C"oAtractors to construct the project -(Sec. 70,,4 Business 8 Professionals Code). r� O I am exempt un r Section B &P.C. for this rens/ n� , Date ,I In i Signature of,©wner_ WORKER'S COMPENSATION DECL/AQATfON -6 I hereby affirm under penalty of perlury4,onof. e _tGie following declarations: () I have and will maintain a certificate of consen(Ito self -insure for workers' compensation, as provided for by Section' 3700 oflthe 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 3T,,,kTp ilt Policy No. 1� 4la•G�1 (This section need not be completed if the permit valuation is for $100.00 or less). certify that in the performancethe work for which this permit is issued, Yshall not employ any person in -any -manner so,as`to•'become subject to the workers' compensation laws,66f California, a�nnd agreehat if I should become subject to the workers' compensation�provislons/of,Section 3700 of the Labor Code, I shall,forthwith�comply..with those provisions Date: APPlicant•- _±1 Warning. Failure to secure Workers' Compensation coverage is unlawful and shall subject an employer to criminal penaltiZ_s and civil fines up to $100,000, in addition to the cost of compensation, d, amages.as provided for in Section 3706 of the Labor Code, interest and attorney's Gs. 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 forte 0 days ill,sGbject permit to cancellation. I certify that I have read this application and dtate that the above information i5l correct. I agree to comply with,.all-Cityf,and dtate laws relating to the buitding construction, and hereby'a'uihorrize re'preseritati6es of this City t er upon the above-mentioned property for inspection' o�s"� Signature (Owner/Agent) BUILDING PERMIT- PERMIT# DATE VALUATION' .« LOT � . TRACT W - X A� 3 r. $170-390.00 JOB SITE % APN ADDRESS 6,54-8). IA 430A RUDIO d - OWNER CONTRACTOR/[ / EN INEER .54.811 AMMAR1:Y1 ID 71509 SAN GUR<iC)W0 LA QiWI.AA Cry, 92233 RAN04010NADA, ... .. CA92270 060)341-2336 MU. 5,486 USE OF PERMIT P001, AMWOR 15PA POMAP,!•i. A ARMISMILRRi.IZ0 SHAIJ, rig IN Ail. ACZ,&T 7: Rb1,IfP...A3TXR ••-• kTtiIPEI �1' <V POOL EQ01.11ME1 T EI'•i{PI.,t7°r`iU°RE NOT;1I $C'I.UDE11�JUKI , TO M0110,M) PERMIT 90112406. 1aOrLM141W >x. SPA w :csrmum Coke` oil, copl 1°RiJ'C: deo j ,4 .ids PLAN CH)WT.1< X 101-000-439-318 �Jg75.� CLYNS`fiRlTt, TI+M F.U. 101.000.41"00 V s :06, MECHANICAL ME -- POOL 101.000421.000 SA, 00 ':Gt:�d f RICAL FIrZ ,.• POOL 101-000-4.20-004 143.00 P1.xF?t Ind"" "Fi:`lr = Poul, 101-000.419,,0 Q, $27,00 LIAR 1 20 LA Qu%%,f A Cl FINANCE OEPT. ;,J,*TOTAT.,t I ON AND P1e,01- T. M, 201?.- �113:i f � RECEIPT DATE p rjnrc BY-yyaT'J 'Q DATE FINALED INSPECTOR :: ✓ ` ' . 7A'fi�R, I &Ii G 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 APPROVALS Steel POOLS - SPAS 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 Sewer Connection Pool Cover Encapsulation _ Gas Piping Gas Test Appliances 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) Final COMMENTS: (J•G/!� — 0 V) C Y DEPT & SAFETY T LWILD A.PPROVED .......... i FOR CONSTRUCTION DATE CITY OF LA QUINTA BUILDING & SAFETY DEPT - ..APPROVED OF BUILDING & LA Q 7 0 7B V] APPR 0 C -TTRU FOR CONS Rl DATE I. -qlk Irk IN ,lam 1 f I-