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0305-045 (SFD)f— CV � W perC,) ' W o Z C(O0O� JV(D �a U) Z M 111 CV ON Ua) NTCL Z U-) ac 0 X LU0 m�U O n L� _Z ob 5 �O J 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 605486 B 1 't 13M-1 ,Date'' ?u Signature of Contractor OWNER-BUILDERf1 LARATION I hereby affirm under penalty of perjury:ihat 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). O I am exempt under Section B&P.C. fog this reason Date Signature of Owner WORKER'S COMPENSATION DECLARATION \ I hereby affirm under penalty of perjury one ofthel following declarations: ( ) I have and will maintain a certificate of consent/fo self -insure for workers' compensation, as.provided for by Section 3700 offthe 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 STAT" PAYND Policy No. 1%56.24.0 (This section need not be completed if the permit valuation is for $100.00 br 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 Ztheabor Code, .I shall forthwith comply with those provisions. Date: Applicant - Warning: Failure to secure Workers' Compensation coverage is unlawful and shall subject an employer to 5�r''inal 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) 'N .fir-- Date BUILDING PERMIT PERM'., DATE VALUATION &t4Sr� .LOT 104TRACT ADDRESS 4:,.'-.M'l:�i I)(WWEA`X)JC DINV;ts JOB APN lam- 3S£:-ft2i OWNER CONTRACTOR/DESIGNER/EN INFER LA ��i7i3�11`�t IN MFA 350, WC. Cra1Ai ' "i'° IVF tvt'it'11ILM)YRS, INC. 5005 f �a•aLUI 9RVW RAP'fIAT"l ITI B-1 5005 CAME SAIT PSA' 114012,, Z TE D I PAU.s. 2110ROCr.3 CA 92,264 TIA1 ,N .`ppW319 CA. 9226.1 iii i(1,f°t2S�4'Mi3 G 3�. E (%67 USE OF PERMIT 3FV, •-,UIT )04.,PL .11•1 4TUTA,LIKMAT U416S KF'Y INQUIUAi. bi.iJCK WAI,US, P001, 1'Nk r.+If irtE1.~:s',!'CTIaN TO FWA r~I:LK.',K;'d�C4agOE7Li'f.?WtE?)�1IPLEi45C�t3�y4�P'•C3:a .4'illtif3a.T9.f Af'i°„P'Ll, TRACT CON 1"I2OC;TI(YA ?,311.011 X31~ 5'ORCIMPAi'iC 1 53,0011 ` �� I41i�i�«t i1FC .t' 4250 UP 1ISDAW173) COST 'OF uOININMILTMON C ON•STRIX11 fx .H. PEE 101.000.4.1 MUO Will59 Iti:I;.C.N,AN.i'cW,n' _ ; it;?•pG'rJ� 2I�L1�tJ S3. G MLWTHICALA3EL 1 u i �;?iiC;� 2C� CDL3fi f 1�i,iI9 1164, , :T1 RONU MOTION FEL • 6:VZY) I Col -000-241-000 $14.54 . c'3WMIi°4 FEE $15,00 1vtl�dL,L�PC?,K l;AR1�,�.C;:f' IAF>i� $?�4[ja.60 a`c;} ',pa. ;:0AFft•T`E u,"' :iow AND 5 I IL KNI OMk:Gia' 1Z 34 :Pa°L-PAMI TIM, 00 K PERMIT M. -.1sly0Z • JAN � k• C1(Y OF DEp'iA REC IPT ATEl:BYM INIOECTOR 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 O.K. to Wrap ' Exhaust Fans F.A.U. Framing Compressor A. Insulation __V Vents Fireplace P.L. Grills Fireplace T.O. Fans & Controts 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 t> Appliances Final Final Utility Notice (Gas) ELECTRIC 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) L APPROVALS COMMENTS: