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0111-219 (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 � . Datefir ,*'%� !�r' l Signature of Contractor ,j p 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 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: Cartier . lTAT dILSD Policy No. 041 6 'V511 MA (This section need not be completed if the permit valuatiori 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' compensatiow-provisions of Section 3,00 of the Labor Code, I shallf orthwith comply with4ose provisions., Date: ,t'.�� ,F / Applicant P J Warning: Failure to secure Workers' Compensation coverallge-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. d, 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 i the above-mentioned property. -for inspectioN!purposes(ts Signature (Owner/Agent) ( _Date 1 BUILDING PERMIT FERMT# DATE VALUATION LOT 011 TRACT 29457.2 JOB SITE APN ADDRESS gg Nt cry g3 y y '&0-10"0 04 t yr. OWNER CONTRACTOR/DESIGNER/EN INEER 4 D D..FA U DSIVEMPWwa WARKS (19O33S".CRUCrIr.O POWEX 17 TO 79-29S.RMIC7,10 LA Q�MUA DR, LAq..101iA CA 92255- LA QtT1.Z!l'tiA. . CA 92253 C/60Yl71 F a'.41 CBS 2996 USE OF PERMIT 11 SV1J t" i1 '?i.AN M:392i;S: ,PERMITfi?C ESQ '+ OT IINCLME WAL-1.4, P4,504 9PA OR )3IUVWA Y APPROACH t;l:STOM CC?ht'ST%.i CT110I( 4,3, .MOD Sig POR.CXffT".f1 IO 552.00 9;F 0�,1(�Fa(�!T4`L.�4k PCl3� 71%)-00 By CONSTRUCTION DUE 101-000-418-000 $1,5460 PLAN CrWKFM 101-000-439-31#8 $512.01 WCIANRRWL VEr 103-000-421 000 $136.50 1±;.LEC9'ltlt AL,:I FFI $IM'•{?0(}-•420-000 $22§tM PLU"MSTWO M 101-000-419-000 W&25 SRCYJsM MOTION FES - RESID .10.1-2510-41 �DDO $:3143 ° . i35`�aKr i 1 f3 i 4t�i7{J-423-Wo . 20,00 I•}plyr,f OP41i IPAP.M.T ME $I,�ifb3.OfJ , ,RT R4 PUBLIC FIACES !illi: 2704W -445x000 • 'a 0111XIM.-UMON, 'AM PLAN CIVIC -M °' j 2®�� �T,L PUMAT V107S VUR: Now RECEIPT DATE .� BY A, DATE FINALED INSPECTORff C1° INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR ,BUILDING APPROVALS MECHANICAL APPROVALS Set Backs ] { —/O —r— _04-1Underground Ducts Forms & Footings I f Ducts Return Air 7 Slab Grade 1 f �� — /�' _ Steel Combustion Air Roof Deck 1( s / 7 _ Exhaust Fans OX to Wrap I I O� F.A.U. Framing 1 { Insulation cS—j Z Compressor Vents _ Fireplace P.L. If Z, Grills Fireplace T.O. I I Fans 8 Controls Party Wall insulation _ Condensate Lines Party Wall Firewall II Exterior Lath Drywall -Int. Lath I I Final It /� N ' �, Final Z— /z - y— S POOLS - SPAS BLOCKWALL APPROVALS steel Set Backs 11 FootingsJ ` _ Electric Bond Main Drain Bond Beam 3, — Z Approval to Cover I I Equipment Location 1( Underground Electric i 3 Final Underground Plbg. Test Gas Piping PLUMBING APPROVALS f , Gas Test Electric Final Waste Lines Heater Final Water Piping i y Plumbing Top Out 1 S��� Shower Pans i 1 Plumbing Final Equipment Enclosure O.K. for Finish Plaster Sewer Lateral ; l _ Pool Cover Sewer Connection I f Encapsulation Gas Piping ) y Gas Test Appliances I f 11 Final i1 COMMENTS: !t if Final Utility Notice (Gas) ELECTRICAL' APPROVALS 11 Temp. Power Pole 1 f Underground Condue Rough Wiring Low Voltage Wiring Fixtures I f Main Service Sub Panels Exterior Receptacles 1 G.F.I. 11 Smoke Detectors 1 y Temp. Use of Power,; I I 11 Final Utility Notice (Perm) I y