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0005-202 (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 697117 :B kI[C� Date 01 Z/O/ Signature of Contractor1�--- 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. cr(-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: Carver S.P11+•I'E Pilaff Policy No. 467.00-0000120 (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 700 of the Labor Code, I shall forthwith comply, w h th se e rovi ions _ G Date: �� Applica -- ; 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 pursuanrto any permit issued as a result of this applicaton agrees to, & shall, indemnify & hold harmless the City of La Quihta, 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 in pection-purposes Signature (Owner/Agent)'`a� Date BUILDING PERMIT PERMIT# DATE VALUATION LOT TRACT I.ti€1 115 25953 JOB SITE ADDRESS 79-434 C:AI'..LE pROS'�ERO APN .604 --328-024 OWNER CONTRACTOR/DESIGNER/EN &NEER 011P1-1AA1T AM VnLLLAM8 ASSOC., WC. ©IxmA11 r AwD wiuAAms Amoc., mc. 77-900 AVEME OF TEM STATER3 77-900 AVE.10M Or, 1111E S'AI-M PALM DIM -R -T CJS 92211 r-, AIM DEMY CA 9221.1 (760)3454=6 CDO $203 USE OF PERMIT 12df1I.3 1=151MY D1gdEILR4G VD -LOT 115 PLAN 5C/ PERMIT DOES NOT INCLUDE 3,1,0CK WALL OR POOL, All OTHER PERMITS RJWLECT 7S0/, REDUCTION 11`O PIAN CHECK. FE9 FOR MULTIPLE ISSU.ANCE OF SAME PLAN TYPE. TRACT CONSTRUCTION x,480.00 3j PORCH1PA110 713,00 SF CZAR GFJCARPORT (Sbo 1ZaVy.60 7XSTM,ATED COST OF C.0XSMU()'E X 148,5,VA30 . 1;'KRi1'11<'1' 1*EF S€I14dMtbRY CONSTRUCTION FEE 101.000-418.000 $811.00 PLAN CHECK FU 101.000-439-318 $167.99 MECH.ANIC.&1. FEIN 101.000.4.21-000 tb4,00 ELECTRICAL FIT% 101-000-420-000 $148.42 PIjUMBINO PER 101 �000*419.000 $160.00 STRONG MOTION FF_V - R SID 161-0007 241-000 $14.86 ORAI: ING PER 101.000.423.000 V0.00 D ELOPER IMPACT !FEE $1,+907.00 ti c taUB-TOT L C''ON U N +A1dD PI_4LJ CF1EC.X. $3,289.27 Lli�93 PRE-PAW.M- S $0,00 A,• 0 T13TAL PERMT FM 8 DUF. NOW 1 - JA�1�2pp O c RECEIPT DATE BY DATE FINALED INSPECTOR i� 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 1fj 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 V' 2 Q BLOCKWALL APPROVALS POOLS - SPAS 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 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 Final Utility 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) Z COMMENTS: WL -L-