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0104-148 (SOTB)CN N W O O � ' W r- Z co0o F - 1.11 F -a IA Z ON 0, °) :- Z u?� Q 0 X W W— m OUU � 0) `t Z ob CY 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: d o( ) I, as owner of the property, or my employees with wages as their sole mpensation, 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. four,Ithis reason Date i% ec, r•1#Signature of Owner �•^" WORKER'S COMPENSATIONDECIL'AftATON 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: Cartier 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, Ishall 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 provi ions''? *'' Date: t f i ,rr .t (Applicant WarFijng: Failure to secure Workers' Compensation coverage is unlawful an shall subject an employer to criminal penalties and civil fines up to $100,000, i addition to the cost of compensation, damages as provided for in Section 370 of the Labor Code, interest and attorney's fees. IMPORTANT Application is hereby made to the Director of Building and Safet for a permit subject to the conditions and restrictions set forth on hi 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 propertflor inspection purposes. e /1111A,111; -,I Signature-(Owner/Agent)�`dDate' I BUILDING PERMIT PERMIT# DATE VALUATION LOT©i-af. TRACT 0 q/yryL JOB SITE APN ADDRESS 11. 9—f, O OWNER CONTRACTOR/DESIGNER/EN (NEER Iwf B:t:,,,t LACK Ovffllfix BU.iMETRI. 79-400 (Wc°i:.k UB USE OF PERMIT MWE!,y.pp.�IMM � gyr�ut'sy [, PIZZA.- .�MS:�s117UMAM S.•bf9,W 0,{C 4,..O+LRiV,H,MMOJr'e ''j, ((''�t��f��ryyqq�pj ppb ,t,�ryyt �{•{j FRY�cRdL�'SaiA"Y,•� ��.,,.r��1.yiw1R'yy.11Y'{�+,,�.V� 0yq-,q!}3tty S4 101-000-439-318 101-000 418-000 SWUM W APR 1 9 2001 CITY OF LA QUINTA FINANCE DEPT rft;Pva®!`i"..yTKL S;tZwsm;vl"'nom mumm, m, c5m ax 8.60 100.1 P:izs �'.y��?t 11 � $0.00 y4ysJ TOTAL .9C�.L'��@'G.�.Y.SL ai. 3' .Y.rrtS 8�6'E YNO `fY �}eg :D$1090 RECEIPT DATE/. / BY DAT LED INSPECTOR i t!! lit INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Underground Ducts Forms & Footings Ducts Slab Grade Return Air Steel Combustion Air Roof Deck Exhaust Fans O.K. to Wrap F.A.U. Framing Compressor ' Insulation Vents Fireplace P.L. Grills Fireplace T.O. Fans & Controls Party Wall Insulation Condensate Lines Party Wall Firewall Exterior Lath Drywall - Int. Lath Final Final BLOCKWALL APPROVALS POOLS - SPAS Steel Set Backs Electric Bond Footings Main Drain _ Bond Beaml Approval to Cover Equipment Location Underground Electric Underground Pibg. Test Final - .PLUMBING APPROVALS Gas Piping Gas Test Electric Final Waste Lines Heater Final Water Piping Plumbing Final Plumbing Top Out Equipment Enclosure Shower Pans O.K. for Finish Plaster Sewer Lateral Pool Cover Sewer Connection Encapsulation Gas Piping - Gas Test Appliances Final Final Utility Notice (Gas) ELECTRICAL APPROVALS Temp. Power Pole Underground Conduit Rough Wiring Low Voltage Wiring Fixtures Main Service Sub Panels Exterior Receptacles G.F.I. Smoke Detectors Temp. Use of Power Final Utility Notice (Perm) COMMENTS: - - , MLI -51 A MEDIO DOME SHAPED ENCLOSURE i 1l EY TOP W/ PAR ARRESTOR 1/8` EXTDR. CEMENT PLASTRR 1/4" STEEL PENCIL ROD RESAR VVRMICULITe INSUL. TWBRpEA,� INSULATING !&LAN (10) fW400EL�UMIsD�a OVEN WWF OVERBILlZ�AT"FOAP.R 10 i' DRY SAND BASE 4* COHC. SLA13 W/44 BAR$ • 12. O.C. EACH WAY L" CONC. BLOCK $q bAR$ 0 It, O.C. +IL C.C. S$.LJIACH WAY BARB "M � IL' O.0 ROOTING fo CONC. $3LOCK 40 AGGREGATE BASE al Id O.C. MACH WWAY s^RS l0It" OC 0 CONE BLOCK -+TITIN 8ASE 1/8• EXTIRRiOIR CEMENT PUASTNQ i• COMM BLOCK WALL �EI.OW VfBRMICIdLiTE 5MANULE9 E%Af 1��'JfsILATINCv Rt��l-T@iltL PRNCII. ROD AB®YE FLUM—MANTIVOLD 'RIN-PAB ' BRICK ARCH CA SERE® M19AiRTH �E OvN 16' PRO"... MIGHT OF OVEN OHM 10 ''16