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0303-122 (SFD)LICENSED CONTRACTOR DECLARATION 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 cel W Professionals Code, and my License is in full force and effect. O :D CO 'License # Lic. Class C Exp. Date r' 0 LOLLI ,6:40 r— Z . D'ate � Signature of Contr ctor OOH ,11 9 r- I.— C)/ OWNER -BUILDER DECLARATION W W r1_ I hereby affirm under penalty of perjury that I am exempt from the Contractor's ~ U) 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). ce)() I am exempt under Section LO B&P.C. for this reason N Date Signature of Owner Oa) Q WORKER'S COMPENSATION DECLARATION p Z I hereby affirm under penalty of perjury one of the following declarations: Lo � 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 O � Q performance of the work for which this permit is issued. m Q () (�` I have and will maintain workers' compensation insurance, as required by O C) Q Sect oh 3700 of the Labor Code, for the performance of the work for which this d Z permit is issued. My workers' compensation insurance carrier & policy no. are: Carrier 19ATN,XNAL UNION F: Policy No. " DO15309 obs r` C7 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,provision�s'of Section 3700 of the Labor Code, 1•shall-forthwith comply with those,provisions. ,Drate: � t 41 t,- Applicant---' � ` 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 111110 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. I X.- 1. Each person upon whose behalf this application is made & each person at whose request and for whose benefit work is performed under or pursJarit 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. fl 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 i • correct. I agree to comply with all City, and State laws relating to the buildin construction, and hereby authorize representatives of this City to enter upo� the above-mentioned property,for inspectier purposes. Signature (Own rr/e _Agent) ~ Dater BUILDINGPERMIT PERMITO#,V1 ?2 ' DATE VALUATION $117,691.10 LOT 126 TRACT 300 + JOB SITE ADDRESS X81-747 bn1`rLEBIS_Ucf( LAN APN 7&41-Vf4 -018 OWNER CONTRACTOR / DESIGNER / ENGINEER SBL ALA QiJIWA,1= M11-1EA HOMES 60.311 TlRTtX)GY PAttICWAr 81.260 .AVWTO:C 62 LAQUOrIA CA 92253 THERMAL, CA 9.2883 '(909)833.8396 CBL40 6V6 — USE OF PERMIT. - - 8rN OIX uA2�lIfi.Y iSdiIF1?T E.�Y+i�3 S b a 1.Vt A, Ad, Puuq -for's. ,. .1W14l l:. !rd Iv 1.d i4 ♦.l.ru ��Y'+a2Ln.i+i', 1 AT,Li� POOL4 811A OR DFUVEWAY,AP?ROACH CUSTOM CONSTRUCTION 11359.00 3F PORC.H31!?A'1IO 714.00 SP i3AJ1A,0FJWP0RT 474,00 SF ISI`.➢I!! ATED COST CSP OCkNFI'RUC.'.7'10N 11.7,691,10 P RRVOri FXE .W&IM AJ" Y CONSTRUCTION J179 101.000.4119.000 $707.50 PLAN CHWX FEE 901-000-43i)-818 ;$572.93 MECHANICAL FEE 109.000,429.000 $'J5.00 ELECTRICAL PER 101-000-420-000 $90,41 PLUMBINO FRE, 101.000.419!,000 $116.' STR.OIdf.1 MOTION FLrE - RE -SID 101-000-241-000 $11.77 OR.t.D NG FEEK 101.000.42.9.000 s[S.00 !D!IVE).,C1P R.IMPA.CT FEE $.2,405.06 r ' SM-�'l'J fAC ! ;Uid.513� z:T; l C)1 .A�2'1� .F'I.A1�9' G"I: $3,989.26 IM.AL 'FFR1%W FUS NOW -DUN �T'it _ 'v art E: KNAN'CF ri.na, •, j RECEIPT DATE BY BY D FI L I TOR INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Underground Ducts Forms & Footings zw, Ducts Slab Grade Return Air ' Steel Combustion Air Roof Deck / Exhaust Fans O.K. to Wrap o•a 3.: F.A.U. Framing 77 — yr Compressor Insulation 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 Gas Piping A PLUMBING A PROVALS Gas Test Electric Final Waste Lines 3.f Heater Final Water Piping 1,Plumbing Final Plumbing Top Out Equipment Enclosure Shower Pans O.K. for Finish Plaster Sewer' 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 Panels Exterior Receptacles G.F.I. Smoke Detectors Temp. Use of Power Final Utility Notice (Perm) COMMENTS: