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9910-625 (SFD)LICENSED CONTRACTOR DECLARATION U) 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 04 W Professionals Code, and my License is in full force and effect. O :D M License # Lic. Class Exp. Date LLJ � �. Z Date �� Signature of Contractor O I 0 F' J 0CIO OWNER -BUILDER DECLARATION W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's ~ N 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), CV) () I am exempt under Section B&P.C. for this reason L N Date Signature of Owner ' O C\1 0) d Z WORKER'S COMPENSATION DECLARATION � Q Z I hereby affirm under penalty of perjury one of the following declarations: r .Q () 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 O 0.: Section 3700 of the Labor Code, for the performance. of the work for which this rn H permit is issued. My'workers' compensation insurane carrier & policy no. are: q11 -Z Carrier ' C{� t F Policy No. y� ` p� ob ry5 ai�f.�,701e A'd-L%': 9YD'I�.rp 3y yY 4'i,�lJ�l. V 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 thhW If I should become subject to the workers' compensation provisips of e'rtion 3700 of the Labor 3 Code, I shadfortb"w� h comply with those pr vlslon Date: Il A/// '7 Applicant v y4rning: Failure to secure Workers' Compensation coverage is unlawful and shall subject an employer to criminal penalties and civil fines up to $100,000; in addition to the cost of compensation, damages as provided for in Section 3706 of the Labor Code, interest and attorney's fees. IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the conditions and' restrictions set forth on his application. 1. Each person upon whose behalf this application is made & each person at whose request and for whose benefit work is performed• under or pursuant to any permit issued as a result of this applicaton agrees to, &.shall, indemnify & hold harmless the City of La Quinta, its officers, agents and employees. 2. Any permit issued as a result of this application becomes null and void if work is not commenced within 180 days from date of issuance of such permit, or cessation of work for 180 days will subject permit to cancellation. I certify that I have read this application and'state that the above information is correct. I agree to comply with all City, and Sta!p laws relating to the building construction, and -hereby authorize represent Ives of this City to enter upon the above-mentioned property for inspecti purposes. ,+ Signature (Owner/Agent) Date BUILDING PERMIT PERMIT# 99l.4t-`F2.'S DATE VALUATION .�'ifa.�� LOT Sj TRACTJOB SITE ADDRESS S 7-919 2hlR�' CI""t iNi ���l�aGIR, 1[ IVk; 1) APN 740-050-008 OWNER CONTRACTOR / DE{SIGNnER / ENGINEER? 3f i1' TCYT'G fAA t' `y' fkfr. A% . �?A . J., ..,4.. 1 %4,46 ... }� ti^,iii % 7,�r•'i~x'ab�a$ds`ITS ie-J�.. . F1423 E. UN IT.Rs1' It, DRUVE, 1 1425" E, UN.iVERSU DRJV A--I0ENIX AZ 85034 PHOENIX A2. W-034 (tlti 1�S+r1� €:131,4N 4090 USE OF PERMIT i ISID14GLE kiR.)- 1,0T 51, lj;uAX `# - i?aWI a K%,S '14 ZQ' iNo:•.f:.iS E BLOCK WiVll CM. ,;'+;:i4ilr. 7Sle 4{�a 1Ui;"�'tr'3'�i i'Iist 4?l.r'�.�t F.'�i �"�" .f��;:.k�d,3:k� fkllrh's`ii?I.� 1:1.¢aly.,0►. QF SAhzf PL :� I TY'PFi +�`f'CJi�t"s".;�+�"ae".�ili".'i`i'r.:+i? 6.�'tfi�l•fi©'w"�' ORCtlf#'A'S.-10 77-W 8 . FY11=11 4 )- Y..4IS!t or C011 STI IC _PERMIT WYNE SUMMARY t�G?Idg"1^.I�ts�f,.'"�`f•�.�%I1FCsli [i/�"li��!m��G�••i7ilV :19rS/Q�.�M1I PLAN 0" f. K, f''9�f� RLtyt.;TRLCALM PLLsMB(Nf.1Ff?!'s rp,RoWt7 kTp; _ R fa 13fJ) 'f Q1 t-Att)F241 AtQ 6� 6.5t1 GRAD. NIG rt IT ART IN,1yflRUC W..,ACTs'S - RC:SID '101-iW-255•MR $162.6-1 i!3 Vjil �JPk3.t 9w.LY�Aty t' IFHF sa,94 n.00. �f.•i SS VIM PAID ITES $0.00 TOTAL PERMIT FEEN DUE NOW sp's"07.91 RECEIPT DATE BY(� D N LE v INSPECTOR INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Underground Ducts Forms & Footings j Ducts Slab Grade Return Air Steel Combustion Air Roof Deck J 2,10 — clo IgLCA Exhaust Fans O.K. to Wrap _ F.A.U. Framing _a_ Compressor Insulation u Zg_C� Vents Fireplace P.L. Grills Fireplace T.O. Fans 8 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 I I 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 �f Appliances Final Final S <4 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 - --ne, Utility Notice (Perm) G Cii, COMMENTS: