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9706-098 (PLBG)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. Yom/ 1 have and will maintain workers' compensation insurance, as required by Sect on 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._ Si'i1°1�ff1:13lJ f 3?lyU^.•9ti (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 p{ovisioWs of Section 3700 of the Labor Zj Cd'e, I sh I forthwith comply with those.pro isions" jaate: � 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 t; whose request and for whose benefit work is performed under or pursuariMb t 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 forsnspection purposes. Signature (Owner/AgeritDate Zo 0OAi'i RAC F A.A %Xl!,rr 1,9()0.00 LS 1,,!)00,00 t??,UN03IIJC,3 MT,, - ;al. -,W 0 -t 101.000-419-M) $:t1 oo ?t �:(. C:�1s`�f9TRWCr1.30N fli�J1a��771tt�t�c.r;AryT�rp�")ry1:.�C+�tyK:FIRE � t+ �[�/t�).{3i) PAID TIFISS �iii.l..^'B"S9d1.J FRE19 � Who AN 12 1997 F�t)1,A1, fi4V. �;�� .�. REgEIPT DATE fBY' i DATE FINALED INSPECTOR LICENSED CONTRACTOR DECLARATION I hereby of that I am licensed under of PERMIT# CONTROL# BUILDING PERMIT C 1 --Chapter affirm under penalty perjury provisions Business �►_�' 5362 04 co 9 (commencing with Section 7000) of Division 3 of the and Professionals Code, and my License is in full force and effect. DATE VALUATION LOT TRACT f 'x1'7 ii 1)(3.00 O D ch 0 LO License # Lic. Class Exp. Date I '- JOB SITE ADDRESS APN 774-193-022 at�ti�1()(�1& _549 AM,��A JUAREZw Z � O �e % _ Signature of ContraCto'r �y / , , OWNER CONTRACTOR /DESIGNER /ENGINEER P OWNER-BUILDER`DE� LARATION N'ljw i�,: ��' 1:t1'C fE(Jti1:11t �1Dji E. Ctt�1l) :;.E's�1f1;R S :TSL"1t !? co W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's I -05 AVEsNHAJIUAREZ, P.O. E3l'7.;�;,192 License Law for the following reason: 1.11. QIJM'A (;A .91253 )•'A1,M ),JFS1:3{T CA 92.261 Z_ ( ) I, as owner of the property, or my employees with wages as their sole (760)346-21793 M compensation, will do the work, and the structure is not intended or offered for USE OF PERMIT 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 Pj..(.jMB Code). ( ) I am exempt under Section , B&P.C. for this reason LOW N)- f) $iR �ti/tA C ONN#Rrf NDate 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. Yom/ 1 have and will maintain workers' compensation insurance, as required by Sect on 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._ Si'i1°1�ff1:13lJ f 3?lyU^.•9ti (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 p{ovisioWs of Section 3700 of the Labor Zj Cd'e, I sh I forthwith comply with those.pro isions" jaate: � 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 t; whose request and for whose benefit work is performed under or pursuariMb t 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 forsnspection purposes. Signature (Owner/AgeritDate Zo 0OAi'i RAC F A.A %Xl!,rr 1,9()0.00 LS 1,,!)00,00 t??,UN03IIJC,3 MT,, - ;al. -,W 0 -t 101.000-419-M) $:t1 oo ?t �:(. C:�1s`�f9TRWCr1.30N fli�J1a��771tt�t�c.r;AryT�rp�")ry1:.�C+�tyK:FIRE � t+ �[�/t�).{3i) PAID TIFISS �iii.l..^'B"S9d1.J FRE19 � Who AN 12 1997 F�t)1,A1, fi4V. �;�� .�. REgEIPT DATE fBY' i DATE FINALED INSPECTOR INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE I 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 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: Final Utility Notice (Gas) ELECTRICAL APROVALS Tempa 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 LM14 Notice (Perm)