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0207-154 (AR)x 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 ✓#, 7sLicc..YClass Exp. Date p Date'n 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, 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 4 - Signature of Owner WORKER'S COMPENSATION DECLARATION L: I hereby affirm under penalty of perjury one of the following declarations: Y() I have and will maintain a certificate of consent to self -insure for workers' compensation, as provitled or, by Section 3700 of the Labor Code, for the performance of the work forwhich,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 I3TATE FUND Policy No. 046-02O1Y.i?338 J(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 proxii6-ions of Section -3700 of ttLe Labor =Code, I shall`forthwith comply with thoseprovisions.'' Date:r 4/�' 1 • �' 1—Applicant Warning: Failure to secure Workers' Compensation coverage is unlawful and shall subject an employer tocriminalpenalties 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 whosel nefit 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.resLilt 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 .epresentatives of this City to enter upon the above-mentioned pr pe y,fooI ns pectio�n jrposes. > Signature (Owner/Agent) Date >`~t•''.�o" _ i BUILDING PERMIT • 'PERMIT# t fD2fpi—i..S4 DATE VALUATION LOT TRACT 08,V4.20 52 29457-2 JOB SITE ADDRESS ; fT�:i �aC,. D �"fYllrf1: APN 6_19,100-s,Iig7 OWNER CONTRACTOR / DESIGNER / EN (NEER :P.0,1• OX 1716 LA QgB11,,t•'.S• ON 92M I'A. q`tD3'I+,fs CSA 92253 (760)771-194! CB0 2996 USE OF PERMIT R.I-Max'.cALa+ 498 S. F. ADDITION TO OMT .F OUSZP UNDER CONSTRUCTION OtJr3i'Y.K.ttP[fAi'IAIoT0 PERMIT 00111.20 CUSTOM CONSTRUCTIOIN 493.00 S IOTIMA IED C OWE OF +CC'lNYMMMON 38 9cao JC tyA�3.7,LLK' i�.Ci.l'N G7N�•RLVAX�d:i� PL&N CHECK FM 101-000-439-318 001`3: T RUC TION T+':EE 101-000-418-000 ��4�.{9i► STti� N. 0 MOTICAN FEE • RMUD 1019000-24-10000 SM ART 'm Pu sI..1'D PLtt,cm �Fsir 2,70 -OW -443-0100 �Sti.99 51♦.C°'PR1t" � 1�1"f loo -000-420-000 3; MA3 D AIM i 3 20OZ CITY OF LA QUINTA FINANCEDEP'T A11W MMI C.�T•ZT2%_ $729.66 °aarAL PlIRMT FriKs.010YINOW $729.66 RECEIPT DATE( i I 1 CS L.- BYE ^� : b f, DTE F L J/ INSPECTOR' INSPECTION RECORD OPERAT ON DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs v2 Underground Ducts Forms & Footings —r1 z Ducts Slab Grade —may Return Air Steel Combustion Air Roof Deck Exhaust Fans O.K. to Wrap —/ _ F.A.U. Framing H— 62ZCompressor _ Insulation h Vents Fireplace P.L. 11 Fireplace T.O. d J Grills Fans 8 Controls Party Wall Insulation © Condensate Lines Party Wall Firewall i Exterior Lath iE Drywall - Int. Lath 14 1 1' 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 I Gas Piping PLUMBING APPROVALS Gas Test Electric Final Waste Lines -pZ Heater Final Water Piping _ Plumbing Final Plumbing Top Out 7227/__,/-_7,:Equipment Enclosure Shower Pans Q.K. for Finish Plaster Sewer Lateral �!Pool Cover Sewer Connection Encapsulation Gas Piping Gas Test Appliances Final COMMENTS: Final Utility Notice (Gas) ELECTRICAL APPROVALS Temp. Power Pole Underground Condit Rough Wiring p� Low Voltage Wiring, Fixtures Main Service _ Sub Panels Exterior Receptacles G.F.I. Smoke Detectors Temp. Use of Powe Final _� ! Utility Notice (Pemto