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0110-069 (SFD)LICENSED CONTRACTOR DECLARATION I hereby affirm, under penalty of perjury that,l 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 i Date i' � -_ ���jSignature of Contr ct r A - 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, Business& Professionals Code), ( . ) I, as owner of the property, am exclusively contracting with licensed contractors,jo, construct the project (Sec. 7044, Business & Professionals Code). O 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: (,,e) 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 th'e 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 VA'3'R.1?$M Policy No.. i s ff3-f9AgX,2 � (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 DateCode; ;IIs IfofivvithA onipant Iho t provisions fF .{ r w• PP Lbw,, )� –y Warning: Failure to secure Workersr Compensation coverage is unlawful and . shall subject an employer to criminal penalties and civil fines up to $100,000, in addition to the cost of compensation, damages as provided for in Section 3706 of the Labor Code, interest and attorney's fees. IMPORTANT. Application is hereby made to the Director of Building and Safety for a permit subject to the conditions and restrictions set forth on his application. 1. Each person upon whose behalf this application is made & each person at whose request and for whose benefit work is performed under or pursuant to any permit issued as a,result of this applicaton agrees to, & shall, indemnify & hold harmless the City of La Quinta, its officers, agents and employees. 2. Any permit issued as a result of this application becomes null and void if work is not commenced within 180 days from date of issuance of such permit, or cessation of work for 180 days will subject permit to cancellation. I bertify that I have read this application and state that the above information is correct. I agree to comply with fall City, and State laws relating to the building construction, and hereby authorize representatives of this City to enter upon' the above-mentioned property �or inspeetlonJ-purposesra Signature (Owner/Agnt) J rr a3h�*>'���, + Date Y�' ' °�',d f� f i, BUILDING PERMIT PERMIT" DATE' VALUATION LOT JOB SITE .p//•.���q;�• g�p �� APN ADDRESS F�•.7✓—�:Ad� .kbk3,Li ._ .�e! a,SA�'A [, !�.i�ii'•AS.tiJ . OWNER CONTRACTOR/DESIGNER/EN PM L& QWNTA. 9968 MERT 31,SUrTE. 102 fW D030 CA 92131 USE OF PERMIT TRACT 285964 64&11XW15 EER MANS WEIr "HOUMG INC 78-103 F 1 -HIGHWAY' t 17 iM - LOT 71 PLAN 3A. PERMIT DOES NK5`'i'' 1N".1I.aUDZ JRL,i3CK WAl.:l % F10+31A'PA C)1$. DR11YFWAYAPPROA.CH, 7SCY6 PLEA1•tC:HWK MIZ REDUCTION V0R..1,81S 4ANCE OF M UVIPI E ?pLA14 T"FVE TRAM!' CfJl`3STRUE,"!IP14 x,$55.00 SN PORI"t�.:l'frATIO 51A.00 SF' 60.90 IF OCT � 5 �(��. Sit -- I..?) ARI3 L );4 Cirl OF LA OUIMI TA FINANCE P --:PT. RECEIPT I DATE JeD MW CM -0c :J 4111 a . PRI&;P.AW Lir' 1=AL.F12WT HUM DUB X0W FI $3,690.011 $0,00 4"�4VT��`.°i"tt.ifr~`•T O►+l k' � 101-000.4188.000 �IaSI�R,50 PLAN M3•#.=l FREZ 101-000-439-318 $214.07 IMukBAWICLALFEE 021to 91 ,CTRICA1.FkZ ra.17 fBgfh'3�xb AzFd�73',d�'AF f�'JfrE • ��..a9:CJ ���-1 •�Datt3-�d'4 �tJi�} ��s.3? R c'9UDAT 3 ME 1200 rieVEM PEF,t IMPAWCT YIET1. $1,9ST3.r30 ART 11`114010 .:1C PLAW - ROME 2'�O:`000-445-M WIN OCT � 5 �(��. Sit -- I..?) ARI3 L );4 Cirl OF LA OUIMI TA FINANCE P --:PT. RECEIPT I DATE JeD MW CM -0c :J 4111 a . PRI&;P.AW Lir' 1=AL.F12WT HUM DUB X0W FI $3,690.011 $0,00 INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs 'Underground Ducts Forms & Footings �_l GL _�!!� Ducts Slab Grade Return Air Steel Combustion Air _ _ Roof Deck 3; _ - Exhaust Fans _ O.K. to Wrap F.A.U. Framing Compressor Insulation 2—. 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 I Gas Piping PLUMBING APPROVALS Gas Test Electric Final Waste Lines Cj / 3 Z� Heater Final Water Piping Plumbing Final Plumbing Top Out Equipment Enclosure Shower Pans O.K. for Finish Plaster _Sewer Lateral _ ewer Connection r_ —�/ Pool Cover Encapsulation Gas Piping Gas Test Appliances Final COMMENTS: Final�j:� / Utility Notice (Gas) ELECTRICAL APPROVALS Temp. Power Pole Underground Conduit Rough Wiring i� Low Voltage Wiring Fixtures Main Service Sub Panels i Exterior Receptacles / G.F.I. A - Smoke Detectors Temp. Use of Power Final Utility Notice (Perm)