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0301-318 (BLDG)LIC:tN'tU C:UN I MAC: I UM Ut(:LAHAI-IUN . I herr--affirm under penalty of perjury that I am licensed under provisions of Chak_ (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 73315 � :!3 ,'E•Ilf:! ::1� �{i13 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.0 for thisreason// Date i 1 ': Signature of Ovfner_, -> lr / 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 VATP,10YND Policy No. W601,W4t` 004, 15 (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 iKl should become subject to the workers' compensation 9rovisions,of S cti Pi 3700 of the Labor Code, I shall forthwith comply with tho a provisions. Date: i :+ 1 Applicant-......._.. , ... Warning: Failure to secure Workers' ComlSensation 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 Au/rp/8ses. Signature (Owner/Agent) - 1' %' ` =/, J -�/ 1 ate,% r ' .` BUILDING PERMITPERMIT # '0 DATES VALUATIONA+ LOT TRACT $14 'k/6/MAii7 JOB SITE �.1. 21 (AIANWIONS --RIVnMA �j✓ - 5 a ADDRESS ✓� APN - OWNER CONTRACTOR/DESIGNER/EN INEER WA WWt VZWJDEV-1W; ASSOC:,1NC I.M.., MM PAC -DIC GEN.i2 AJ.. C0Mr9W_ Xit plod DOX 11060 2S33 80UTIT WAST HIC'3kf'WikY W1, 750 LA QTRk4'tA C.;.il1 92253 CA RL)n1F F3' T!W SE& C_ -1k 9200t 7 t' 60),5535.1010 (M-41. 58r4 USE OF PERMIT HLD0. 21: ii -ISO, 55-34 _i5,-245S54K VOLUNTA11Y STRUCTURAL TURAL MODIFICATIONS, VALUATION W WNSTRUC"T'IOAI.IEE 1011-000-418-000 51(1© STRONG MO TION iii? > RIESID 101-000.24,11-000 $1.40 FEB 0 3 DIOF LA QUI FINANCE DEPT. .Y t:;l':IlP-170TAL (:'C'rN 7.110M 11'P1Y°> PIAR3.C''MC11C. = S154.40 LESS FRE -PAM 71= $0,00 TOTP[, PRBC "MISvri C HOW $154,40 r , r iM RECEIPT DATE r`� By-,:-. W .r- D E FI LED INSP INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE -7 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 Beam Approval to Cover Equipment Location Underground Electric _ Underground Plbg. Test al 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 f Low V Aage Wiring Fixtures Main Service Sub Panels Exterior Receptacles oke Detectors amp. Use of Power Final Utility Notice (Perm) COMMENTS:::