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0308-054 (SFD)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 7287.02 D lac f� 9/311!()`_4 Date P'/`3 `�' 3 Signature of Contractor OWNER -BUILDER DECLARATION I hereby affirm under penalty of perjury that I am exempt from the Contractor's License Law for the following reason: ( ) 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,.Busi6ess & 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'OLD REP'U1�LIC' MISU Policy No' WC10084:490 (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': �r "'1 f� 4-3 Applicant '�L-��✓-i1.+�'r `=. Warning: Failure to secure Workers' Compensation coverage is unlawful and shall subject an employer to criminal penalties and civil fines up to $100,000, in addition to the cost of compensation, damages as provided for in Section 3706 of the Labor Code, interest and attorney's fees. IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the conditions and restrictions set forth on his application. 1. Each person upon whose behalf this application is made & each person at whose request and for whose benefit work is performed under or pursuant to any permit issued as a result of this applicaton agrees to, & shall, indemnify & hold harmless the City of La Quinta, its officers, agents and employees. 2. Any permit issued as a result of this application becomes null and void if work is not commenced within 180 days from date of issuance of such permit, or cessation of work for 180 days will subject permit to cancellation. I certify that I have read this application and state that the above information is correct. I agree to comply with all,City, and State laws relating to the building construction, and hereby authorize representatives of this City to enter upon the above-mentioned property for inspection purposes. Signature (Owner/Agent) � � T % - �` -�-f .� Date BUILDING PERMIT PERMIT# DATE VALUATION LOT TRACT - S0120.292-40 1.39 29323 /=;v - / 'i- JOB SITE APN ADDRESS 79-9X5 4.:©RrE Ci�.i.ERO 609-380-023 OWNER CONTRACTOR / DESIGNER / EN (NEER LRION.f R HO11 S OF CAS Uk)RNI1A LENNARMaEs ore CNLWC3R1+ILk 78-400 C W01MALY 111 79.401 C 1HIGHWAY I I I 1AQil1", UA CA 92W T.,AQ2UWTA CA, 92253 (760)7770111. MIX 3434 USE OF PERMIT .� SINQUFAMU:.Y.D :y.l.1tT0 SFD - LOT 139, PLAN IYC. PERMIT DOES NOT IAfC:L.UDV, BLOCK WALL40k P001., SPA. OR 13tRii/1E:'ti1V,�Y APPROACH. 75% UDUCTION TO PL ),T CH9Ci1 FEE 1 tft'1`0 Mtti,' IPL E ISSUANCE OF S.fil f PLAN TY109 T AM' CONSTRUCT1014 Z041.00 8F P6Re:1$ P.A, 10 . 5100 Sir 0ARAC+.MA+. .PORT 1447.00 SF S171"XI' COST IV COMMUC'Y`ION 120092.40 CONSTRUCT], ON "IF 101-0001418-000 00 $ 713.°00 PLAN CH'Lt'GK FLEE' 103-0130.439-316 $14-7.93 MECHANICAL FEE 101.000-4;ZI.000 553.5() FLIr.L`. RICE'L E'EN 101-000-420-000. 1�URPfk3lfiiCi H" :E 7011.000. ,19.000 STR.ONO MOTION FLIP, - F,.I.NSID 101-000-241-000 $12.03 GRAD1140 PEF, 101-000.423-000 $15.00 D..17WELOPER IMPACT FZZ $3,405.07 S'1M TOTAL Ct)MURUC':CIC3N A )PI: W r.'1~1 -C,1~ x;:3,615.99 LT£SS PRE -PAD) FF=I CS,Ot1 Tf)"1'l>,T.1< -MRM 'I' IT4M Y➢VE .P Mr RECEIPT DATE/j BY /. SPECTOR INSPECTION RECORD OPERATION71 DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs U :erground Ducts In Forms &Footings ucts Slab Grade / ReturnAir2 v _ Steel _ _ _ _ Combustion Air Roof Deck _ Exhaust Fans O.K. to Wrap F.A.U. Framing _ ✓ _ ompressor�� 1AA Insulation lents�//fAIAV 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 LFP"h-OVAI1SZ64p:::� Steel Set Backs Electric Bond Footings Main Drain Bond Beam Approval to Cover Equipment Location Underground Electric Underground Plbg. Test Final Gas Piping PLUMBING APP VA -S Gas Test Electric Final Waste Lines J 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 _ i Appliances Final COMMENTS: Final Utility Notice (Gas) ELECTRICAL APPROVALS Temp. Power Pole Underground Conduit oe Rough Wiring Low Voltage Wiring Fbdures Main Service Sub Panels Exterior Receptacles G.F.I. Smoke Detectors _ viv- Temp. Use of Power �-s Final Utility Notice (Perm) ' V t