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0306-494 (SFD)U) H (V U) W O =) co CYW CS Z CD I.— _J ~a U) Z c'o N ON U_ °' Z Lr) Ia-0 X W 4: mUU d rn H It Z ob Z) Cd J LICENSED CONTRACTOR DECLARATION 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 Professionals Code, and my License is in full force and effect. License # Lic. Class Exp. Date trtlfi4$�i �i ? 11�t;1'fi� DateIT' U Signature of Contractor OWNER -BUILDER DECLARATION I hereby affirm under penalty of perjury thatI am exempt from the Contractor's License Law for the following reason: lk ( ) 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). - ' ( ) I am exempt under Section - , B&P.C. for this reason Date Signature of Owner WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: ( ) 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 performance of the work for which this permit is.issued. ( �); I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' -compensation insurance carrier & policy no. are: Carrier :TATE FUND Policy No. 17()914-03 (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 subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions. Date: - i-!'. 'Applicant -- ''+ Warning: Failure to secure Wor,KersCompensation coverage is unlawful and shall subject an employer to eG urinal 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 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) %' ,"--� Date �'�'' •^y BUILDING PERMIT PERMIT0�-494 DATE VALUATION &V20,292A0i LOT 122 TRACT 2%323-1 JOB SITE 43'�Y35 c0iMI PrIT., C.tRID ADDRESS APN 6W21 O'23 OWNER CONTRACTOR/DESIGNER/EN &NEER i A QY7kd" [ A MM0 350 DEVRODI-E S', !NC. 5005 C,AdUX RA PE''AEL.11I'S 3'! 5005 C_AL-L.t-' 3AW 'R �!�'H , = B I If ALM. '.i,'?RYN13:3 CA VZV4 P.AT,.C,r3, TRR1kYC 3 CA 922" '?60)325-4789 x:310 Gee 'let USE OF PERMIT i'wt;9L}%'E NbdLY Dwy.r6lma , 34' w t5,' ii-ty PLY.4< 1 %k C&:..at''CA 51 16"t atr Wl';V ycrB WALLA P004 SPA 0& PRAf"WAY APPROACH TRACT CCsN2 TRUCT1 14 40411 Do VF POR.C31•I,rFI'.fL111.110 53.00 Sty' 447.00 Mir PLAN CHECK ME 1(t• -06U1439-316 iti9i 11,4t41CAL FEE '101-0010-421-000 ELECT3ICALLFEE PLl°MIMNO FEE S5'RO140, 1ACY110V FE • XESI ? )OV -00-2,41-000 �gte�.fb3 0W—)IW..0T'V. 1tilR��SIM �3d00u �d�.tfC3 7'3f.VZU'')PfM 3 APAC'T I E 67 A-`.I°4J"tAL C01V.8RIX..75ow.Y`aiVD.Y."°[ytpp�adf xr�p4��ryy:"A.i".fqq.9T�lr�f $4,04-2.(4/`.' {�y.��] ACJ ]?:N..i:i &Tff 119i)Z? Ir N©W S4,062,+150 AUG 11 2003.. CITY OF LA QUINTA FINANCE DEPT. RECEIPT DATEBY I DA FI INSP CTOR 002 INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Footings Underground Ducts Forms & Footings _ 3 S Ducts Slab Grade Return Air Steel — / --3 Combustion Air Roof Deck Exhaust Fans O.K. to Wrap Framing F.A.U. Compressor Insulation Vents Fireplace P.L. Grills Fireplace T.O. Fans 8 Controls Party Wall Insulation Condensate Lines Party Wall Firewall Exterior Lath Drvwall - Int. Lath / Final Final PLUMBING BLOCKWA L APPRO AL Gas Test Electric Final Waste Lines steel Set Backs Electric Bond Footings Main Drain Bond Beam Approval to Cover Equipment Enclosure Equipment Location Underaround Electric -SPAS Final I I Gas Piping PLUMBING APPROVALS Gas Test Electric Final Waste Lines Heater Final Water Piping A Plumbing Final Plumbing Top Out 1z Equipment Enclosure Shower Pans O.K for Finish Plaster Sewer Lateral Pool Cover Sewer Connection Encapsulation Gas Piping Gas Test Final COMMENTS: Final n A 1 Utility Notice (Gas) Cr`' r V ✓ V ELECTRICAL APPROVAL Temp. Power Pole Underaround Conduit I i , 1A �. Low Voltage Wiring Fixtures Main Service Sub Panels Exterior Receptacles G.F.I. Smoke Detectors Temp. Use of Power Notice