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0207-115 (PAT)
LICENSED CONTRACTOR DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of lI�.— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and - C14W Professionals Code, and my License is in full force and effect. O 5 M- License # Lic. Class Exp. Date W r 5'Z) D52 D03 WC, 0613012( L, Z ii�_ /Date,-/ 7 Signature of Contractor , ._ `" ! �_X2 o JCD 0 I— OWNER -BUILDER DECLARATION HW ~ I hereby affirm under penalty of perjury that I am exempt from the Contractor's License Law for the following reason: Z_ ( ) 1, 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). ( ) 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business & Professionals Code). M ( ) I am exempt under Section B&P.C. for this reason O N Date Signature of Owner 0) d WORKER'S COMPENSATION DECLARATION p rr I hereby affirm under penalty of perjury one of the following declarations: Lo H O () 1 have and will maintain a certificate of consent to self -insure for workers' X W LLcompensation, as provided for by Section 3700 of the LaborCode, for the m_ Q performance of the work for which this permit is issued. Q L) ( ) I have and will maintain workers' compensation insurance, as required by O U Q Section 3700 of the Labor Code, for the performance of the work for which this Il rn ti- permit is issued. My workers' compensation insurance carrier &policy no. are:. I- Z Carrier S'tATat.FUN[. Policy No. 167.402-D! co S t` O d (This section need not be completed if the permit valuation is for $100.00 or less). _J () 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 Maws 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. . Date:Applicant 'F k z••.� Warning: Failure to secure Workers' Compensation coverage is unlawful and shall subject an employer to criminal penalties and civil fines up to $100,000, in addition to the cost of compensation, damages as provided for in Section 3706 of the Labor Code, interest and attorney's fees. IMPORTANT Application is hereby made to the Director of Building and Safety for a permit , subject to the conditions and restrictions set forth on his application. 1. Each person upon whose behalf this application is made & each person' at whose request and for whose benefit work is performed under or pursuant to any permit issued as a result of this applicaton agrees to, & shall, indemnify & hold harmless the City of La Quinta, its officers, agents and employees. 2. Any permit issued as a result of this application becomes null and void if work is not commenced within 180 days from date of issuance of such permit, or cessation of work for 180 days will subject permit to cancellation. I certify that I have read this application and state that the above information is • correct. I agree to comply with all City, and State laws relating to the building construction, and hereby authorize representatives of this City to enter upon the above-mentioned property for inspection purposes. 'Signature (Owner/Agent) -L.. 4 1' Date '-7/d %. BUILDIN�G`PERMIT PERMIT// + DATE !� X46 /ryplp VALUATION �p py (1 LOT TRACT JOB SITE ADDRESS e ° 4rZ'J3.LAZTTJ0 S-1 APN OWNER CONTRACTORI rNh,,NFFR ZU.O 111 k" IFAMU, ZVI` JAMES FRI0G%.s ".. MFR, dba AM..AKF CO, 44 46y.5qP3BLMAN0 �: .. 5?6 R.O.I` D, . yy yry pp IA CA,t: _9122533 PALM. U 90-'2(4 (760)327•Z2w� t: IR 052.57 USE OF PERMIT RATIO 213SIP ALtUOJ13PAIO CL1OR 196 SIV Ri,tA1lV01)PATIO COV' . I , PEP, 1LP,OVRD AA5& i'LA4IMPATIO J"i',yV QRS 17MA COOT Of C OP�.1"$Z1' CTION 6,m.2£1 'yj7 `� j ihirr 'jam RUMMY PIAN CkMIX. Fitt'. 101-000-439-518 MUD STROW MOTION RE - �=K M1,0004741-000 too sam-$:�.3`:f`,r•`.oOw�w�` NOW crn of FINANCEOE�• t RECEIPT DATEf BY, �: ,,N.. DATE FINALED INSPECTOR 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 POOLS - SPAS 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 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 Gas Test Appliances Final Final Ut�la Notice (Gas) ELECTRICAL APPROVALS TerrC?- 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 ZZ,00© L Final Utility Notice (Perm) COMMENTS: SCI OF LA QUINTA BUILDING & SAFETY DEPT. APPROVED FOR CONSTRUCTION DATE 17116102 av d;;�o L -- JOB: Timothy Easterly 44465 Blazing Star Trail La Quinta, Ca. 92253 760-360-1252 e L ro 67 5'Vv P _K Y//tcj� P I� P�+1 /p a.�— = y ALCLARE CO., INC. 576 S. Williams Road Palm Springs, Ca. 92264 760-327-2227 Lic.#390323 City Lic. #05257