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0011-255 (SFD)W, LICENSED CONTRACTOR DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of CI ipter 9 (commencing with Section 7000) of Division 3 of the Business and P,r1,fessionkls Code, and my License is in full force and effect. License # Lic. Class Exp. Date ' 7141 . D -0// �i l// i =Y�7) ate, j Signature of Contracto�r � 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 owher 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 370b of the Labor Code, for the performance of the work for which this permit is issued. (�)o 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. 001.DEX RA.OLE IN.9, NWC,,14406$•02 (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. Die: n h- Zr.•, Applicant'_;;r51--) --R - 1 , i c.:./. C. Jv 1 r a, -r a Warning: Failure to secure Workers' Compensation coverage is unlawful and shall subject an employer to criminal penalties and civil fines up to $100,000, in addition to the cost of compensation, damages as provided for in Section 3706 of the Labor Code, interest anis attorney's fees. IMPORTANT Application is hereby made to the Director of Building and Safety for a permit 'subject to the conditions and restrictions set forth on his application. r. 1. Each person upon whose behalf this application is made & each person at whose request and for whose benefit work is performed under or pursuant to, any permit issued as a result of this applicaton agrees to, & shall, indemnify & hold harmless the City of La Quinta, its officers, agents and employees. 2. Any permit issued as a result of this application becomes null and void if work is not commenced within 180 days from date of issuance of such permit, or cessation of work for 180 days will subject permit to cancellation. I certify that I have read this application and state that the above information is correct. I agree to comply with all City, and State laws relating to the building construction, and hereby authorize representatives of this City to enter upon the above-mentioned property for inspection purposes. ''may 1 fgnature (Owner/Agent) + ;x f ,-'-4 Date 1'2^ 122!ef, BUILDING PERMIT PERMIT# VALUATION LOT t�•`i'vS TRACT DATE A)D100 92.3,113WO1 Fs 2W71 JOB SITE APN ADDRESS 7.1?,'%0 BAYA 1169-490,042 OWNER CONTRACTOR / DESIGNER / ENGINEER C.fWWRY CROWTc . COUNT l.BS CY. VIRY ("Rowaa:L co). "Jwl i a gs 1535 sol `!fig o wi, UM 0200 is 35 �7, `7V MCM71 MT, Mo SAN BrB RNARDW r CA 92409 SANDF2NARDTHO CA 924"' (gopol-6im CDIX 2120 USE OF PERMIT / �(y��Y'��TT�n ggqq•• �� y /,S rry �r q•y •ry9'�j� .S�LIVQJy1l�AMfL D%V i l tll7 ' LOT 8, .f1LA`4 IC; �,`Y D - L7="NOT INCLUDE BLOCK WALLS, P004 OR DRIVEWAY APPROACH. .P1 N CIIECK lqE itFDl� ICE!E 7$V*.'CSR. MULTIPIZ Issti"Clc OF SAMR PLXN TYPR. CUSTOM CONSTRUCTION 21815,00 SFS POECHIPATYO 157.00 Rkr 0AR&OWCp,RPORT (3F) O,S .4tt X&MA'I9D Mgr OF 4°0HS'1T3 Jt"'d'iC)N 231 IM .00 Prfmr. F0.9 so 'FVi[+b,TKV' CO3;iR'1'3?UCTION "Mi, 101-000-418-000 5111011" I, d (101i.ECK FEV 101-000-439.318 $312.47 MECHANICAL. W 101-000-421-000 03,50 =CTRWAL. i?EE 101-00"20-000 PLPUlh1 t31`rt01�L 1 U1 �FFt�Ci-� 1 �^tFi}(3 �td�.5t? STRONG MOTdON FEES R.I .HJD IOI- 300-2AI-000 1U.14 OkADDIG .F. . 1014=423-000 $26,00 AL*V'ELOPEI; IMPACT .11tr P,,907.00 ART IN Punk PL&as . mir 7wyOf)t'J•%ti3000 M38. n 1 9S' M&PA rD FRIO $0.00 VD , I'M ERWV FUS ME HOW DEC 12 2000 .— UN RECEIPT DATE BY. t.1 D NALED DI0�:1 INSPECTOR V,../-7-0 INSPECTION RECORD ,c'. OPERATION DATE I INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs 11 A/ Underground Ducts Forms & Footings Ducts Slab Grade O Return Air Steel Roof Deck _ l G Combustion Air Exhaust Fans OX to Wrap _ � A/ _ F.A.U. Framing y 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 ! A/ Final r f� Final POO '.SPAS BLOCKWALL PPROVALS 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 Z Z %' Heater Final Water Piping / Plumbing Final Plumbing Top Out Equipment Enclosure Shower Pans O.K. for Finish Plaster Sewer Lateral j/ Pool Cover Sewer Connection i© Encapsulation Gas Piping Gas Test Appliances Final COMMENTS: 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 011/ Final Utility Notice (Perm) 7