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0301-173 (RPL)LICENSED CONTRACTOR DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of F- Chapter 9 (commencing with Section 7000) of Division 3 of the Business and 0 W Professionals Code, and my License is in full force and effect. p ch License # Lic. Class Exp. Date 690045 B Inc: etc/It Z ti Date �' `�'' r. , Signature of Contractov^ -- •-^� """b---^ �(]�f F U OWNER -BUILDER DECLARATION LU UJ I hereby affirm under penalty of perjury that I am exempt from the'Contractor's ~ V) 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). cr) () I am exempt under Section , B&P.C. for this reason IO N Date Signature of Owner ON 0) d Z WORKER'S COMPENSATION DECLARATION lir I hereby affirm under penalty of perjury one of the following declarations: H0 ( ) I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by Section 3700 of the Labor Code, for the DJ Q performance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by j' V .Q Section 3700 of the Labor Code, for the performance of the work for which this 1 H permit is issued. My workers' compensation insurance carrier & policy no. are: Z Carrier 11'1',x.1`1?• FIRID Policy No. 1U733000_02 0 �0 g (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 su ect to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions. f%Date: T ^� !g!. t Applicant 4-� 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 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 - Y 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)" �- A *•-_ Date-, BUILDING PERMIT PERMIT# ' J 03fI3_17 r DATE lj .. VAIN i}TIONLOT99 TRACT , 11 r JOB SITE ADDRESS yEd'.�i Clii!.R© �E�T*!r� APN - OWNER CONTRACTOR/DESIGNER/EN (NEER 1.1"1; Hamm Liz xB90. PO 130X. 810 1425 F', 'UXAri7tknt T!° DIRLI E I.A. (j NTA CA 92253 0_10a=- AZ 85034 (6b2pv.i 65 G MI dt TSC° USE OF PERMIT 1' OOLaW7OR ,%. A ?COlSPA,BBQ:V.T d!0914).,4L:^MS18.AT[:CSSiALLB3XN P1ACRA PRE -PLASTER 1."SPE.0 En1t. EQUIPMENT }3OWSty1.�40T I's My'r d:✓A.3JdJSf" uh,1 0F i. nL•4i.i%iJRI.'{.7JCTEO:n•C MOii•F1I 101/ PL -VI C'14&.CK FIX, 101>000.439.316 $M130 CGNS'I'RUCTION ME. 1101-000-418-000 $162.00 M.HC ANICAL.FEE;.-POOL 101-00 04"l-000 $24.00 9LEC.TR.1C: kL FEE <. POOL, 101-1000-420-000 -�45.00 iPL11,( RINCI 1~11;F.-- Pool, 101.000.419-000 z OX1.f3.-TO ' L C"L'?N' iRl.7t~TIC9W A.'t1) FLAX C,1 -C1 4E: i�.�icl LE 33 PPM-PAJUJ FE9 3 $0.00 l "r,1:1as ITYUu NOW, z1 0TAT-e Yui D JAN 14 2003 t a CITY OF LA QUINTA - FINANCE DEPT. RECEIPT DATE ln BY� DATE FINALED 303 INSPE '+ t�f 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_ POOLS - SPAS BLOCKWALL APPROVALS 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 V .ante Lines Heater Fina! Water Piping Plumbing Final Plujnbing Top Out Shower Pans Equipment Enclosure O.K. for Finish Plaster Sewer Lateral Pool Cover Sewer Connection Encapsulation -- 3 Gas Piping Gas Test Appliances Final COMMENTS: 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 t Temp. Use of Power Final Utility Notice (Perm) .. .. :�,�^ .....,rwy,;7�L3hY;•'�JiF'f�R!'r(,/i'y�1v :'r.: �•.•i,l �•a,:Cr.12;'S� ''rr� So 62.6 e,,r+�/,moo prr.►•A l �1iYl 8�n 6.6F; mi liw iN3i�N9I In L33HS N Sln 43d. NOL►V_S/ XOd . CITY OF LA QUINTA BUILDING & SAFETY DEPT, APPROVED FOR CONSTRUCTIM BY >:':;:•- ,.,,.,fir„•,,..