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0212-222 (BLCK)LICENSED CONTRACTOR DECLARATION I hereby affirm under penalty of perjury that I am -licensed under provisions of Chapter 9 (commencinlg 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 649905 C-49 '✓�,!' Date _�-1h:;4,, - Signature of Contracto�r� OWNER -BUILDER DECLARATION 1 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:. Carrierlk v coRp e�f�' .m.zl d, Y Policy No. 100091414 (This se� n need not be completed if the permit valuation is for 1$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,'1 shall forthwith comply with those provisions.�� •r �.. Applicant �..� �d-,rf/ 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, 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 ; r, 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 ature (Owner/Agent) /�•riJ�:t� ^�© e �1'%+' ✓' - - �'.�:✓ ;ter • a,,''�f• "' ;' r�''� • �.:� � Y. PERMIT# :. a BUILDING PERMIT -, 1 j VALUATION LOT • •TfACT; JOB SITE ADDRESS - GCS APN OWNERE CONTRACTOR /DESIGNER / EN INEER06 — Ka-DRS]I tT SABOR MAMMAY 4 9.4199 H1331W13O'tMOM DR 1625 ?RC':[:EMC STR=u , Nl-1 LA Q't INTA CA, 92253 P.A.TA DY3S tRT CA 92260 (W)674.0666 t`"18L4 414 - USE OF PERMIT Gi„NiT..TW, WX MWG 360 .L3" 8`'t1J.,C1C:E," W,AU, MR ORC0 m4TANDARD 014 "a HE .-SO JT'rl,'IM&ST V OK611 f1 OV VfaMELO AND Xf PERSON PER CMAPPROVED ED PLAN, b FT, WALL 300.00 LF - XFP_KdVrFD C.C35T Ole CONa'I'RUC"!TON. PERM1ri`(FF. E��{1iM�E�o1`�.�RY ✓(� r'�y (I'O `7 )f.f1.t:aC RDD RZ j\J1^l%5!Va^f1 FY•VJ"1JV ii7iiV� Tan D I�► TD F oIR. VERIiFYaILL ,r_--�.�_~_ . - --�• •.i.fUBS 1.OTAL O.iVJ@Td,1tVXi:+dAO3.V b'7ND P1,J%1, ��1.:Id:.V1Cr.- '�a•+'r �,• �---'Jig. 6oio - - ... is rins nin pA , n 9 " $t3, ou +. ' e a . � 121001 RECEIPT0 ABY (� DATE FINALED INSPEC R ,Lf ,�''jrC. ff�-° 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 8 Controls Party Wall Insulation Condensate Lines Party Wall Firewall Exterior Lath Drywall - Int. Lath Final Final BLOCKWALL APPROVA POOLS - SPAS steel Set Backs Electric Bond Footings Main Drain Bond Beam _ Approval to over _ Equipment Location Underground Electric _ Underground Plbg. Test F0 %I r Gas Piping PLUMBING APPROV Gas Test Electric Final Waste Lines Heater Final Water Piping Plumbing Final Plumbing Top Out Equipment Enclosure Shower Pans AO. 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 Dough Wiring La,v Voltage Wiring Fel fres Maier Service Sub "Panels Exter'pr Receptacles _ G.F:� Smok Detectors TempAJse of Power Final 41 Utility Notice (Perm) KI COMMENTS: