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0303-294 (BLCK)LICENSED CONTRACTOR DECLARATION PERMIT# U) I hereby affirm under penalty of perjury that I am licensed under provisions of BUILDING PERMIT 03W.3-2'9 4 F- Chapter 9 (commencing with Section 7000) of Division 3 of the Business and DATE VALUATION U) $3,!5,15,W LOT its - TRACT 30023- 04 LV Professionals Code, and my License is in full force and effect. O ch License # Lic. Class Exp Date d (MG934 , B fi Q/Q3 JOB SITE IADDRESS 61E-73511 MM-98 UG4:iL,tiNE APN _ r.//, r 1 r] Z � Date ! d �.3� Signature ofgontrac�t0 ��i•h i •' �`��il� „�,, OWNER CONTRACTOR/DESIGNER/EN INEER t` f— o OWNER-BUILDER DECLARATION MK& 1101"S SMA, 1_10WX _J U Z 81-7,60 AVM M 62 81-260 AVS 62 LULU I hereby affirm under penalty of perjury that I am exempt from the Contractor's LAQXTNTA CA 92253 IMM AL. CA 9218$3 n. U) License Law for the following reason: (909)833-6996 MR 6876 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 USE OF PERMIT ( ) I, as owner of the property, am exclusively contracting with licensed/ MURAL 33LTMMIG contractors to construct the project (Sec. 7044, Business & Professionals. Code). iK1 tt, 0=eo a I .x t vs ~i11C �.Vta sT6R YtF F. V Ca/ 8 tcJ ce) () I am exempt under Section , B&P.C. for this reason LO N Date Signature of Owner O0) Q WORKER'S COMPENSATION DECLARATIONEL Z _I p 1 hereby affirm under penalty of perjury one of the following declarations:%a. 3�3,�� p, "HT=. Lo H O O 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 m � Q performance of the work for which this permit is issued. Q () (���) I have and will maintain workers' compensation insurance, as required by O Q Q See on 3700 of the Labor Code, for the performance of the work for which this 11 0Z permit is issued. My workers' compensation insurance carrier & policy,no. are: Carrier ZvA7'I �idllk. 4Jl')F l� Id Policy No. Y�g530S+ Eb"1�N>Gt%?i�TD Coss Off' C�iI`7,'t"�'Ift'iDA;'�SCi?�: )_s?'� ,0o C3 PM. M PER SUAMARY J06 5 (This section need not be completed if the permit valuation is for $100.00 or less). COI�l3�"T UCTION' FEE 1X11.000 41'0.003 X63,00 () I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to becomeisubject to the workers' compensation laws of California, and agree that if I should become V.— It .. 3 subject to the workers' compensation provisions of Section 3700 of the Labor Code, i shall-forthwith comply with thosei0rovisions. I oQate ' '° K!1" ,,-. Annlioant,/' I[i..r`$PJ 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 APR 0 3 2003 addition to the cost of compensation, damages as provided for in Section 3706 of the Labor Code, interest and attorney's fees. CITY OF LA QUINTA IMPORTANT Application is hereby made to the Director of Building and Safety FINANCE DEPT. 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 M-D-'�'�Gf' AL CONST �.�,Tf.'°i ON'f{'t� D PLAN C�FL�C:' , $63.00 whose request and for whose benefit work is performed under or pursuant to g,�LS' k"'fi-PALLS F;1 QQ 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 TOTAL 3'N,.�1: MES DUE NOW 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. � p RECEIPT DATE, BY E FII LED I R Signature\(OwnerA)geli't)!`1'�1�� �Yra.� Date -'`' Wil. !,' ,, fes': -COY 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 J Bond Beam 0j 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 Utility Notice (Gas) ELECTRICAL APPROVALS Temp. Power Pole' Underground Conduit Rough Wiring Low Voltage Wiring Fixtures Main Service Sub•Panets Exterior Receptacles G.F.-I. Smoke Detectors . Temp. Use of Power Final Utility Notice (Perm) COMMENTS: