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0304-255 (SFD)' LICENSED CONTRACTOR DECLARATION I hereby affirm under perialty 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 1 Ezp. Date Date- .t 'Signature of Contractor ! ► Y- �`"`"`^��-'� i 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. '(,"-) 1 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 WAT$CM''R Alr UNIUN F' Policy No. ft+e 83: H (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 oSection 3700 of the Labor Code; I s all forthtwith comply with ihdseprovisionsi. Era te1'' r .. '1 Applicantl....r� 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. I 1. Each person upon whose behalf this application is made & each person whose request and for whose benefit work is performed under or pursualin any permit issued as a result of this applicaton agrees to, & shall, inde & hold harmless the City of La Quinta, its officers, agents and employ 2. Any permit issued as a result of this application becomes null and v work is not commenced within 180 days from date of issuance of permit, 6r cessation of work for 180 days will subject permit to cancella I certify that I have read this application.and state that the above informati correct. I agree to comply with all City!and State laws relating to the bui construction, and hereby authorize rebresentatives of this City to enter upon the above-mentioned property foginsplection purposes. Signature (Owner/Agent)' E6 j l.i ., T.. fti�• BUILDING PERMIT PERMIT} DATE VALUATION LOT ACT TR 'Jj+V,7. tat db JOB ADDRESS APN 7&t -A" OWNER CONTRACTOR DESIGNER (NEER SHFAI.-. & Q'f7llwi (� rix,, BITF k„RON 60 -'ti )'I�it Il Cr' ':i7�'z�2::Z,b�i:'�'�' 80.1-126D 1ei't I UE CA 92813.111 USE OF PERMIT uNCi•L` T.�`A2iSi.7P :tVY :r�i;> 1 0 ^ 1AJI 149 I-Ef"R ULA, ,.I v:! !*RctUT-tit,!Jr U_,._ Y' CIJ9i'r:'1? GC�l�S3'< 33';31'I 1,!Q.9 #iF ,PtiCtC;I-.iliaJa.`4'i© a3i..f1t; Ar t3tl=}A<!E'Isti J69(''fs ?I a3a.11t aF L:tAP 3.Y.CA„Ci'A� teY��`.0 �d.F' 'II MSQiY2 �A.a.V 4Y (4Y•�AJ.�7 .7.N94:•�'�'.•': •. Ji.� PIMA& FE 0700TRUCTION PIE 10' -000-418-000 VAN RL &V4 CKWX PER- 101-000-49-316 $6251.* MU("IRMCC.AL FUR 10 j -1100-421.000 tGt f - RICAY> FEZ 01-000- 420,•C 00 PL,UMM00 FU 191-000-419-000 STfi.ONCI XICITION 'VRP a t&S-1f) f01 -000 -NA -000 CittlDDII3 KBE 101.01)0-423.000 a{III ti .UVELOPER IMPACT PE $440i0 T &°1;WAL CON`.�."'f: IMC s,70"N AND X—AN C:IMCK 13 TOTAL JI.Xa'f.+. V11KRYJT 3.1.Si G.i1 DUE NOW eTYDp.i s¢�A�.s�.eD ZAPR81003 uINQTA —PS L RECEIPT DATE r: BY J f / D T�FINU� � o,/� 4��1 d INSPE INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs 4 Underground Ducts Forms & Footings 4V 41 Ducts Slab Grade Return Air Steel If I Combustion Air Roof Deck ff Exhaust Fans OX to Wrap —z - 3 F.A.U. Framing Compressor Insulation — 2 —-3 Vents Fireplace P.L. Grills Fireplace T.O. Fans & Controls Party Wall Insulation Condensate Lines Party Wall Firewall Exterior Lath7 Drywall - Int. Lath Final Final. 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 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) COMMENTS: