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0305-041 (SFD)LICENSED CONTRACTOR DECLARATION C/) I hereby affirm under penalty of perjury that I am licensed under provisions of H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and N W Professionals Code, and my License is in full force and effect. O =) M License # Lic. Class Exp. Date o Z r— ",Date '-3 `'=' Signature of Contractor / / U coo OWNER -BUILDER DECLARATION W W r1_ I hereby affirm under penalty of perjury thl t I am exempt from the Contractor's ~ 0 License Law for the following reason: Z_ ( ) 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). ' c'•) () I am -exempt under Section , B&P.C. for this reason LO N Date Signature of Owner ON d Q WORKER'S COMPENSATION. DECLARATION p Ir I hereby affirm under penalty of perjury one of the following declarations: Lo H p () 1 have and will maintain a certificate of consent to self -insure for workers' X W �= compensation, as provided for by Section 3700 of the Labor Code, for the mJ Q performance of the work for which this permit is issued. Q I have and will maintain workers' compensation insurance, as required by OU Q Section 3700 of the Labor Code, for the performance of the work for which this 4- LO H permit is issued. My workers' compensation insurance carrier & policy no. are: l?' Z Carter STATE 1" JhD Policy No. )17JiQ4_0J obd J (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 3 subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisl'Q,QS ,-..-, Date: S jJ_ '.Applicant (11 (Warning: Failure to secure Workersf,Compensation coverage is unlawful and shall subject an employer to crim�rial penalties and civil fines up to $100,000, in y addition to the cost of compensation, damages as provided for in Section 3706 i 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 pursua any permit issued as a result of this applicaton agrees to, & shall, inde & hold harmless the City of La Quinta, its officers, agents and emplo 2. Any permit issued as a result of this application becomes null and v If, work is not commenced within 180 days from date of issuance of h permit, or cessation of work for 180 days will subject permit to cancel) Ion I certify that I have read this application and state that the above informati n i correct. I agree to comply with all City, and State laws relating to the bu ding construction, and hereby authorize representatives of this City to enter upon the above-mentioned property for inspection purposes. Af, -Signature (Owner/Agent)r �✓ p �`" "j Date BUILDING PERMIT PERMIT{ DATE VALUATION $14!j a.c 0 LOT TRACT JOB SITECs�.F.r3f 3© . ' � � � . : ADDRESS APN W; - OWNER CONTRACTOR / DESIGNER / ENGINEER '_./f��/�Q��f;�E3iqA���'PyY14�t^;J@L1Ai�i�i�� :�r3i91,(.I7�it.. i%!rl t;�O??'id!i�.;7';iY� ri 00"5 \..C..IeLtC:�• mw tl?,. ,&-n.,C2d "-Cry%" B"J /;:)��grtXn`iC�7?(R{.T.ifLr. -.5Of,)5 �:N�`t�.1.1, -/.tSbw .1�.!•5L3.JL'ELi, S,)1. Bl PAU." t 11 P1IXG19 CA 92264)�tairTh� lsa 3 ' �I .�. C.A 92264 d7ti(} j? 2 t.'F33.1, 5867 USE OF PERMIT ,ij <'. -Li 1. W; C1LXN. r_K1n(d11 I "c'Es 1+,iX+I 1e4 t.A.WE_Af. Clif:U l to T3ii'e F�J (fE!L'fXPi C. '1^3iYAT901' O S€>i�Sdi ��].T ? 'r .'i' C=NSTR1.rG'F ON ::<'jl,? . saSJItMlflE?#.TIO _'531,10 241' .fit;' n:M-Th"= (70k';T.Ok Lr'�J11S.U,'X R' ON. P IM11I-ON11 SU314 Ky ",45,3 .. 0 CA .19 ;F},F��+E,y . �Y1:) t ••C^ 00-,oq"3.- wK AP11AXYY1 VS7l••ryO.bt�.E!�-.S,'►Fay.yyk��•SGC".?r:• Tr��YI:eJ�r,0 ts,1000 Ilii /l,21-0+0 W C.Yha,Y JF�u1L Yb'•L:.• s.ie n-'{d'�FI'•>R s.����i:v! �q.t}'. C7� ;PFe�:ltv]F�B23F,1' � ��`� f f ! •i��n6�1�19»OCu o3[�i,`P:i S'PRONUM"CITI NFEY,.RESH? 2t)9•,)DO-241-000 i ST PB,'F.0T:r'LCON s:,fia.o UAW, .L�uC+3T.id.A JF.'.[;.3',�f 8�+1d,?x .����..?�:`9 1'•�}i'YWPIf rJ JUN 0 2 2003 ITY OF LA QUINTA FINANCE DEPT. RECEIPTDATE f ),� BY DA A //�� I NSACTOR INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs erground Ducts Forms 8 Footings A Ducts Slab Grade iV Return Air Steel Combustion Air Roof Deck Exhaust Fans O.K. to Wrap F.A.U. Framing f -15,c Compressor Insulation _ Vents Fireplace P.L. Grills Fireplace T.O. Fans 8 Controls j Party Wall Insulation Condensate Lines Party Wali Firewall Exterior Lath Drywall - Int. Lath Final Final POOLS - SPAS BLOCKWALL APPROVALS Steel Set Backs Electric Bond Footings Main Drain Bond Beam Approval to Cover Equipment Location Underground Electric Underground Pibg. Test Final . Gas Piping PLUMBING APPR VALS Gas Test Electric Final Waste Lines Heater Final Water Piping Plumbing Final Plumbing Top Out Equipment Enclosure Shower Pans OX for Finish Plaster Sewer Lateral Pool Cover Sewer Connection Encapsulation Gas Piping .� Gas Test Appliances Final COMMENTS: Final Utility Notice (Gas) 47, ELECTRICAL AP RO.VALS Temp. Power Pole Underground Conduit Rough Wiring Low Voltage Wiring Fixtures Main Service Sub PanelsJv- 14 40 Exterior Receptacles G.F.I. Smoke Detectors Temp. Use of Power Final Utility Notice (Penn) _EE41 / 4_11