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9907-600 (DSF)LICENSED CONTRACTOR DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of , f„hapter 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 410-104 12/31119,,.� D tt ` `�' S ��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 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 Policy No. GOER:. , I &WI rdw'(.'" X60103 (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 withthose provisions. Dte::I- �'� r `d 1 Applicant /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, indemnity & 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. Sig a ure (Owner/Age �'f �*���'� "��-'Dater � BUILDING PERMIT PERMIT# �9tT7»tr(10 y DATE /� �, VALUATION ss,t')d.181 oo LOT TRACTJOB SITE ADDRESS 'i4-8.50 (, A' IT, V .P.LSL'C.liiX) APN 1 `OWNR CONTRACY. TOR / D/ENGINEER �Ey �+ q� �y 11, /y AESIGNER �t�7( wT�OM 4450 CA1.LE PLAC IEK) P.O. HOX 11.88,1'C1fd BA LINDA 926% LAQlfiN'1A CA 142253 CA"1ir1EDKIM.UTY CA 10234 (61! )3:24-7929 CAI* 3819 USE OF PERMIT 3_t131WjL r 6UK DFA (OL1175N 01' FIRE T'3.f1h)AOF VALUATION 1S,04.0111 LZ r.=.3i'Mt'kTE1q COSI O (X)NYfR 1{'") ION 31{3MIA") 111CRJ'F cl.l.T FEE SUMMARY � bVNI(A ATION, FEE 1.lJ S .iltY0�4�3 0()tD Sd �.iit3 r Sof: =1'rMAJ. CON15"1'ROr"1' ON ANY) ;,11 -AN 01!HC9v fat 0fti LESS v iJ �l.r ♦ J ..,, -d u i TOTAL PF3tMIT "�;k;S b)tifENMI S45.00 RECEIPT DATE BY , y� . DATE FINALED INSPECTOR INSPECTION RECORD ' OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Underground Ducts Forms & Footings Ducts Slab Grade Return Air Steel Combustion Air Roof Deck Exhaust Fans O.K. to Wrap F.A.U. Framing Compressor Insulation Vents Fireplace P.L. Grills Fireplace T.O. Fans & Controls Partv Wall Insulation Condensate Lines Party Wall Firewall Exterior Lath Drywall - Int. Lath Final Final POOLS - SPAS BLOCKWALL APPROVALS Steel Set Hacks Electric Bond Footings Main Drain Bond Beam Approval to Cover Equipment Location Underground Electric Underground Plbg. Test Final Gas Piping PLUMBING APPROVALS Gas Test Electric Final Waste Lines 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 Appliances Final COMMENTS: Final Ufility Notice (Gas) ELECTRICAL APPROVALS Temp. Power Pole Underground Conduit Rough Wiring Low Voltage Wiring Fixtures Main Service Sub Panels Exterior Receptacles G. F.I. Smoke Detectors Temp. Use of Power Final Utility Notice (Perm) JUL-23-99 FRI 10:31 RUTTMAN CONSTRUCTION Ftl Dox 1180 Yorba Lina CA 92W) (�4) 993-3320 34W Bankside Dr., #D Cathedral City, CA 92234 324-7929 RUTTMAN CONS•1-111JI&ION 7603218624 INTERIORS INC, STATE LIC. NO, 416304 P. 02 SI~RVICINC, COUNTIrS r Eos Angel©s ► Orango O ftivetslde ► San Rernardir• San Diego (714) 993.3320 • (W# 394 7 (800) 624-928/ tnyvranceCo. of Farmers Insurance Group of Companies 7-22-99 AdiuJUno 1',rn•, --- ___........ Date _ ___ Address _. _,12•-057 111 City - Ranchd C& Llp_�_1�,10 NOTICE TO ADJUSTER Mr,S__Shannon- Lund _ , you ora hereby requested to attach this roan lU Proo(of Loss, theretwmaking RUTTMAN G0N5TRUGTIONjINT ERIOAS INC. an interested oarty to this claim. RUTTMAN CONSTRUCTIOWINTERIORS INC. Is hereby authatizad to clean, repair, or rop►ace the ssmo and In dolno 60. Ig 0Cling Solely for the underslped and not kH any Insurance company Or 40n1paMi0f, or any of its repro6entatives. NOTICE TO INSURANCE COMPANY--A89ICNMENT OF CLAIM -COVENANT OF PAYMENT This to to (nMruol the Inauranca company or compAnlea, whd may be liable lot this lost. In whole or In port, to pay to RUTTMAN CONSTRUCTION/INTERIORS INC. moneydue or tobacornedue in eonnectionwith work hereby authorized. or to insert the name of RUTTMAN CONSTRUCTION/INTEA10R8 INC. irl 3nydetrftordrafts made In payment of raid loan, (/we agree to sign Proof of Loss promptly so draft can be Issued and when rentittanCb iS reC8lvod, to andOrsA S8 nA over to RUTTMAN CONSTAUCTION/INTERIORS INC. In the. amount due tilt}m, Wo further agree RUTTMAN CONSTALICTION/INTE.RIORg INC, has llmtted Power efAltornoyto ondorse and daDnsft to its accounts any insuranrn company checks or drafts relating to said assignment I/wo agree to pay direct to RUTTMAN C0N3TRUCYI6NI INTERIORS INC. any amount which is not covered by my in9urance company. for Any reason. AUTTMAN CONSTRUCT10N/INTWORS INC., SIM$ OontrActoea License No. 416304, Contractor Claso 6.1 whose W,Ine_j9 address 18 P,Q. Box 1188, Yorba Llnda,CA92886, andwho s h d1n ft rTiorre tU as"Gontraclor' end _ - I�6u(j ��,whose address is 4 8�� AQl le ; i o Lam a, CA is herainatler referred to as "Customer', agree 68 follows: 92253 1 A th� V1Y _ 1g 99 a loss occurred wnloh damaood On or about the �,.,,.,,..�.�......_. day et � 4 certain otollony owned by Cusfomer. Gustomer herebygUthorl2esGontractor to repalt. remodel. alter,conYor% clean, or replace tho dOM600 dono to tho property. - board-vp and demolition - The throe (3) this noUp W CanC I this Contract Is h4rebywalved as providedin 01v11 CodO500tion 18e9,13 because of tho emergency due tu�,t �!�1>?►��� ---, -. '���"""„ - 7his document shall be dwoLd nn effa? by Customer until accepted in wrltlno by 106WScter 8t Ce111`400 B hofne office. CONTRACTORS ARE REOUIPED BY LAW TO BE LICPNSEO AND REGULATED OY THE CONTRACTORS' STATE LICENSE BOARD. ANY QUESTIONS CONCERNING ACUNTRAGTOR MAY BE REFURKLDTO TI tC AEGISI'n,\n OF THE BOARD WHOSE AUURESS IS. GontraetOW State License nonrd 1020 N. Siroot SECraplOnlG, California 95814 22,ydf Ju�Y 1e 99 0l Palm DESer.t' — Cpltitornlh L•xecutad this,,,,,,,,,, nd .. —' "CUSTOMER" U'd, --_ 01 so- AcA:i cepted by ConlrActOr RUTTMAN C0NS1'nl)CTI0Iq/INTERI0n5 INC.