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9611-031 (PLBG)LICENSED CONTRACTOR DECLARATION I hereby affirm under penalty of perjury that I am licensed underprovisionsof Chapv9 (commencing with Section 7000) of'Division 3 of the Business and ` Profe§sionals Code, and my License is in full for,( -,and effect. License # Lic�lass «' Exp. Date i809f):t f✓ - 16131no7 i I.!/ ate r � 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, Bu$ine$$ & Professionals Cade), ( ) I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business & Professionals Code). O I am errzem t under Section B&P.C. for this reason Date i /�,%� Signature of Owner t 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. Q) I have and will maintain workers' compensation insurance, as required by Se, tion 3700 of the Labor Code, for the performance of the work for which this permit is ;issued �v1yJ_;workers' compensation insurance cArrier &1;pglicy no. are: Carrier Policy No. (This section need riot 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 with those;provisions. Date: i t tw% ApplicantQ V - Warning: Failure to secure Workers Com pensation coverage is unlawful and shall subject an employer to criminal pe7alties 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 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. `• Zignature (Owner/Ageniir-_-AX__;/J Date j //�lf V BPERMIT# CONTROL# BUILDING PERMIT �,��_�>� 4804 . DATE � 1f�i.�!'t)f► VALUATION �� I� �� LOT TRACT JOB SIfE.6' ADDRESS 50-790 CALL L ovao APN OWNER CONTRACTOR DESIGNER ENGINEER GMryyttr2t 4G ry . . ECrtOS1WFR.}i,PIt7 Ct 68-8128 :12:AMON TL AID 84035 C.A'F3•AWl X0, C'A:11.4113.~ikALCl'1'`. CA. 9M4 PAIIM DUSEXT CS V72,61, USF OF PFRMIT PLU M I -ANG SESITf.0 1V6ANL►_)N f SAWER H00;KLA) VALLA! IoN 1,4+itl. O .LS ass,cj�fi.l.3.f�+f+�c�7�lz.-�t;`vis �i)t•-tm�i•F��i7c� �;x�).o� LESS PIM . -PAID PUS' SU,W NOV 12 1996 `i." YfAI., PK 411 FEWS VUE NOW SM." 1 BY — I fry RECEIPT DATE BY/ -•-� 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 Party Wall Insulation Condensate Lines Party Wall Firewall Exte 2r 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 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 w / Final COMMENTS: Final Utility Notice (Gas) ELECTRICAL APPR ALS 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) S"ts"�!rn..�• ' „+'ty''` rv{ r.4 �p►�.� mss. 1/A WMMM DMTRtCi -_ ServlceAddreser Ac ��rJMf r F �A V A CtOd9 7T 3 ~ 4 �9w J : \ U g rf �M6�6f(�l�in`'�2-+6'�. �„ err. .�' "3s r: �:' ,t.'-•*.�`..c 3;,, Y`. ''k.. i.f sok ca Tf .i" �.r yr z�., Sefy�Ce(6) ..�. ,.i., .� ,i: -.. ff _ :. .7? .� =k >y.L 4 ' r ��. ♦.. s s .K _ � -�^'�: i _ r7- �,s„` r r -r E_ c. f'� _ ♦° °�. ..TM % e .kms �F"�5.. Ts t.'S. 8 f r. so LAt"W"i icYorCheCkW t*4WSiiih a 7 c ET UncAlt�cted'A000unt O�insprciion F"" Tact r ` r Q�`QOrld Pl�rlNrit is-a" "s� t •9ond� �' � , a . ��• E�,�C4+stton►ei QePoatt � � � _ �+o k t Y L49 CkaTT T'+` is OEM 47947 ,. ut�a.r„r iury yr wenn. rF PAYMFNIT TFRMq NET In DAYS FROM nATF nF SERVICE i%% PER MONTH CHARGE AFTER 30 DAYS 04 TOTAL MATERIALS ATE 0 OR ER CUSTOMER'S ORDER NO. PHONE M NIC HELPER STARTING DATE DATE COMPLETED WORK ORDERED BY " TOTALAMOUNT $ BILL TO ORDER TAKEN BY ((( ADDRESS ' /1 Q DAY WORK (� ❑ CONTRACT CI ...— r ❑ EXTRA JOB NAME AND LOCATIO JOB PHONE ut�a.r„r iury yr wenn. rF PAYMFNIT TFRMq NET In DAYS FROM nATF nF SERVICE i%% PER MONTH CHARGE AFTER 30 DAYS 04 No one home E] Total amount due ' Ef TKtal billing to--- Signature for above work: or be mailed after completion PROOIK,T 259.1 ds tnc � i hereby aa 01471. of the above described work. acknowledge the satisfactory completion Of work Groton Bk TOTAL MATERIALS TOTALLABOR PLEASE'PA4 FROM THIS 1NVeieE NO STATEMENT WILL BE MAILED, TAX DATE COMPLETED WORK ORDERED BY " TOTALAMOUNT $ No one home E] Total amount due ' Ef TKtal billing to--- Signature for above work: or be mailed after completion PROOIK,T 259.1 ds tnc � i hereby aa 01471. of the above described work. acknowledge the satisfactory completion Of work Groton Bk