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9606-021 (SFD)I— N to W f Q Lo CDP:o) LIJLW(0 H CL (n Z (Y) N ON U a) Q cc - Q O m J Q U U O rnH 't Z_ ab 5 �a Q J 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 Date Signature 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, 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: Carrier Policy No. (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 shalt forthwith comply with those prov s.e s. •Date:��� Applicant' � 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 foroi sn pection purposes. �-- Signature (Owner/Agent) ..-�- Date BUILDINGPERMIT PERMIT# CONTROL# «+►I 3481 DATE S��♦y VALUATION LOT TRACT JOB ." APN ADDRESS 77-1;9(1 C AL1,11, (.1111114JAIRU „ 773-311-014 OWNER CONTRACTOR /DESIGNER /ENGINEER 1). h1;:IJU.! ( 0N.S**TRUc,110N1 735Y)jV,BRrAI'JE)W5 Gid., MT. `11110 711-i.3IONI DR. UNn' I VAIM fJ!'s`EW1' CA 02260 PALM Df,"SWIl' CA 92460 (t 19.1776.0011 777-0604 Q3f14 ' USE OF PERMIT :;11'1+:11.1 1-ANJI1,Y (: WPI.LING c^0N'('RA.0 I'c�R. ilTA31t3K.APERN•OT 13279 KH, ISSU171)140 KE',. 1701,11IL r D C0N,1TIR(X,7Y1 )`N itITLACT0 V1rRIf DN, rf,W- PAN , L.S'i'IMAITY) COST 0- CONSTRUCTION OAXII PE RMI f YETC SUMMARY i SUB-TffrAz, CONSMI UMON ANIS PLAN CHECK $0.00 ISL Pix('41AID F'E so 001 'fMAL 14!}.N?4UT YEWS DUE NOW $0100 RECEIPT DATE BY DATE FINALED INSPECTOR INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR 4...�'UILDING APPROVALS MECHANICAL APPROVALS Set Backs Underground Ducts Forms & Footina;,?,F Ducts Slab Grade Return Air Steel Combustion Air Roof Deck Exhaust Fans OX 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 BLOCKWALL APPROVALS POOLS - SPAS steel Set Backs Electric Bond Footings Main Drain B nd 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 Fbdures Main Service Sub Panels Exterior Receptacles G.F.I. Smoke Detectors Temp. Use of Power Final /Z Utility Notice (Perm) COMMENTS: U) N U) W E; Z) M r- d u) W Z � ,T O r - W I 0) www H Il U) Z M U7 N I Z �Ir �O 0 J J mUU O d 0) Nt Z_ ob Z) �O J 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 Date���� 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, 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: Carrier Policy No. (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 Shan forthwith comply with those provisions., Date: `� Applicant v' »!✓'.-."�•'” 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 inspection purposes. Signature (Owner/Agent) Date? - BUILDING PERMIT PERMIT# CONTROL# 9611WOZI 3445 DATE 0 54/96 VALUATION 15.11{) LOT TRACT JOB SITE APN ADDRESS 77 -VA OILLIX ('11HIUAIRIA 773-.31.1-'014 OWNER CONTRACTOR / DESIGNER / ENGINEER 111 Vif,S::tr] I' ,E'l-A.I.1 IC0,1I"ITUC" Tu111 77290 CALLS CHIMUNIIIJA 7.IAS JON; DR_ UNIT f 1A t- IANTA C,A 9225; PAIN DFrShkl' (:'A 97260 777-4602- (: E%I.If i USE OF PERMIT CCINIVAt;;I'i;,}3,0(ANOVA' M&HT 15279I IMSSC31IA)W)R- , r.X) fl:9l,. 1)t.,ONSTItUCTIt0N f2!"P WAr'f!:f)WITH 1). i41F9 1'I,f.l t;t)WIMC; I`t�N COMPANY. y �� j M'fi 1 MATED. c_UST t;ti+' i,.ONSTR.W..C.ION O.06 1':1PajRMIT F 1+ E SUMMARY Sf. B-TMAL CON,M"fZUCrION AND PLAN CHECK $0.00 LESS PRE -PAID FES 50.01 TOTAL,PERIMIT FIMS DUE NOW RECEIPT DATE BY DATE FINALED INSPECTOR w 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 APPROVAiS steel Set Backs Electric Bond Footings d 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 COMMENTS: �� 7/✓�/Ci i �/L 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)