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0210-017 (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 74 4 B HI.C� V3 /i? Date'�•� �W. � Signature of Contractor, rf- 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 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 STATE SUND Policy No. 046•0200OWS (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 with,those provisions. -- JJ ,©ate: �.'. �'' '< a Applicant �s f 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 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 i6;pection purposes. Signature (Owner/Agent) (., l" '� ' Date f -BUILDING PERMIT PERMIT# 3.tL C1'Y DATE VALUATION LOT TRACT 2� 7 22t3.€p.52M 14 2,9457-3 JOB SITE ADDRESS 7.9-977NC710 TA QU a�T. A,11).EIM, APN OWNER CONTRRACT�Oy9R/DESIGNER 1NPEEERR- qy qyl !Yr?Y t�t^la���7 AV LII, "L�.r.IJE �+5-.�>.c.lrtc."acV1 DIM c/EN U.E7i•S.L4KIS C�}Y'�ery.cS�f.Jl...TIO PO BOX 1716 79-295 RcA&"WO TA QU'iAi Tei, DR. LA eW-YrA CA 92253 L,P Q7_M41A CA 92253 (760)771-1941 Mill 2996 USE OF PERMIT SFD - LOT 111� E'fdr'.d1.NTO 1: Pl t"r:MIT 00 -CS R T INC)sUDE BLOCK W.AL1AR, P004 81P,,k OR P;)RAV-8WAY.41.i'F'fiG.I;SL'`H 75% !'1...A14 CHROK NO, RV;DUC` IO14 FOR MUL'1'11 IXISS'UANCE OF S E PI. -AH T'YPZ. CUSTOM CONS'1'RUC'.'WN Z6.9y100S3' PORC✓f3lPATIQ 767,00 F O:ieRAGW.,ARPOWF 614,00 SF E1911m, WM0 War or, C(')?3� ,1,T?,,UaTJ0X 22052100 ;9?1 EY.Mn':FER 9MMARV CONSTRUCTIONFEE 1431.000,4183.000 51.0611109 PIAN +:1a1LUK ?ZZ 101-000-499.318 $217.90 MECHANICAL FEE 101 mEiiti3=4Z1.000 210,00 ZLEVr°R4CAL "X 101.,000-420.000 slao1 PLUM1INGVa. 101-000-41"00 $174.2+ s'1'1 om ZRgo2' m Few. - rs.FmD 101-000-2A1-,000 $22.09 GRAWK0 FU, 1431 -000 -423 -batt WIN EDEVZiOPERR.3tf?.PA1 T lrtt $1,405.4.00 AtT 11'8 P1l:BUC PLACES - RESM 270-000445.000 W,1;3 5 StiB-'3:Ui° If 3QiS�"IMLYC1`i011 AA.ND;PL{ANT Ck:.X. $4,71 38 a6` P.11- SpdT{Iws..� pL1 2i : TIF, flow QCT 3 u 2001 TA R CEIPTPT BY f DATE FIN EDINSPECTOR INSPECTION RECORD i�e OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR :BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Underground Ducts Forms & Footings Ducts Slab Grade — —,7— Return Air Steel z Combustion Air Roof Deck / — Exhaust Fans O.K. to Wrap s F.A.U. Framing -2 Compressor Insulation Vents Fireplace P.L. Grills Fireplace T.O. Fans & Controls Party Wall Insulati)n Condensate Lines Party Wall Firewal Exterior Lath - Drywall - Int. Lath Final Final SLOCKWALL APPROVALS steel POOLS - SPAS Set Backs Electric Bond Footings Main Drain Bond Beam Approval to Cover Equipment Location Underground Electric Underground Pibg. Test Final Gas Piping PLUMBING APPROVALS Gas Test Electric Final Waste Lines (� / — �% Heater Final Water Piping Plumbing Top Out /� / Plumbing Final 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 (Gast ELECTRICAL APPROVALS Temp. Power Pole Underground Conduit Rough Wiring _ -- Low Voltage Widrg Fixtures Main Service Sub Panels r ,� Exterior Receptaaes G.F.I. Smoke Detectors Temp. Use of Power Final t Utility Notice (Perm) COMMENTS: