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0308-0010 (RPL)LICENSED CONTRACTOR DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of ,LL 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 656128 rw53 Hi:C., C-8 1OM3/2( Date"} Signature of Contractor OWNER -BUILDER DECLAR TION© 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 9 Prnfessinnale r:nrio) ( ) 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 reasori 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 SeE & 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 (;O11R}��p. 30ATI Policy No. 04-64168-2003 (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 t dse provisio44 e ns. • Date: , Applicant o� Warning: Failure to secure Workers' Compensa fion 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 Y` 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 foreinspection purposes. Signature (Owner/Agent) ice+ %�� Date >!� Ni L'OING PERMIT PERMIT# DATE VALUATIONLOT., TRACT JOB SITE .ADDRESS'" - +rrw...e��.'.•ur;�nn�ri+;wa•P�/rtnitroxav�rn:+ J!7Gi.473 OWNER CONTRACTOR/DESIGNER/ENGINEER QUARRY RANCH 11C, . OAL' BURMA P..0013 1 P AS t;rOP MAN CO I QUA -PIR � LA 86-100 �'VEME 1: A Q' ,.A � CA 92253 00AC L A CA 92236 C760)�98d9222CIE140 00M UDC Or FERMIT POOL, SPA &-.] LF., .i` 81AC3C WAL4 C -IT Y STAI-I ' ARD POO) MTiD1tsR SPA. 17,6775,00 LS 3 Fr. WALL 15.00 LIQ' � E5'.M'I,AZ.'I� IX COW Me CORS17MC, 4 oil 17,999.75 PIMA= F12 9MEWMY PLM (,HEC=K FEE 5122185 CONSTRUCTION FTE. 161-000-41 LR -000 $189,00 ItfIF.C'•EI LAICAL FEE -- POOL 101.000-421.000 S,7A,i10 ELECTMIC&L FEE •. PO()[, 2 Q17000-420-000 $45.00 Pfl.LiMFsIWO T%E �-TOOL 101>.000.419-000 $27,00 =.0 TAL CO='RLT(°:'i`IUIdCAND PLfr'N' O11.'ELM. $40.85 .. LESS ME -PAM ME, 50.00 n AUG 0 8 '2003:: CITY OF. QIUINTA FINANCE DEPT: RECEIPT DATE BY DAT ALED .Q INSP .. 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 Exterior 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 -AP ROVALS Gas Test Electric Final Waste Lines Heater Final Water Piping Plumbing Final -Plumbing Top Out Equipment Enclosure Shower Pans OX for Finish Plaster Sewer Lateral Pool Cover Sewer Connection Encapsulation Gas Piping Gas Test Appliances Final 7j COMMENTS: 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)