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9908-137 (SFD)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 avid Professionals Code, and my License is in full force and effect. Lice. se # Lic. Class Exp. Date 7 4.j4'1 10131./1.91 ' ate 4 ' Signature of Contracto OWNER -BUILDER DE RATION 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. (4 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. ' GOLDEN EACILE INS, 'NWdC .3440613-+1.1 (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, V shall not employ any person in any manner so as to become subject to the wor�prs' compensation laws -of California, and agree that if I should become su,,3�lect tot wor ers' compensation provisions of Section 3700 of the.Labor Cbder�omply wtto ipr 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; ih 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 correcct✓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 tthd above-mentioned pro kerty.,for inspection purposes. j Signature (Owner/Agent' Date r� r BUILDING PERMIT PERMIT f37 DATE VALUATION 2d3f3,8s7. i,D LOT 30 TRACT 20.451? ell ADDRESS �'i4�-f 56 C:6I,.1�LE i�IO�t.3t E APN 760-.02 03.9 OWNER CONTRACTOR/DESIGNER/ENGINEER C EN11 11ft AY F.,.R`J'Vprl'i.LL C'tJMkv1Li1Y61. IES L4N1 i i.YR.Y \..PO ELL Cl.rir"1IvPJ +1,1'lr-S 13:15 SO. "D- STRER T, 9M. 9200 01-W14I84M. SAN BE .NA IDINO CA 92408 SAN 8FRNARI31NO CA 924013 {9i1v13€il'1 0131. 232.11 USE OF PERMIT 1 jI= eta �)� } Pt.UMBr.NG Fa SINGLE FAMILY DIVEL.LINO $ t621 Ai 5YRONG t6 OTICy'R F.U. • - REST) Yy SFFD - LCYF 30. PiXN, 3R - PERMIT DOE'S NOT-INCLiJL E BLOCK WALL GRAWN•C.I+E ;f3E t [3-42A-oIi14 OR POOL, 7$% RB)LIC"1'SC">'NC1ta PLAN CHFXX Fes? OR MClI.' PLP fAR.'1' IN PUBLICF:f',LACM3 - RLk'SIU 70 1 -XXII-255-WO $233.1.4 1S:IURANCE OF SAME PLAN 'i,1rPT'. CU Tii OM CON STRTJC; r10N Z."93.00 SF PORCIFR.0.10, 213.00 &F G. ARAG.FJCAra-,, Jxr 5CA.00 3F E "k 1T1+iA FJe,0 C08T OF CDMTRUC"PION PERMIT FEE SUMMARY ' CONSTRUCTION TR:UCI ION FEE 01-W14I84M. �3a3.Cif9 K.414 C EECK FEE 101-53+ 17.439-318 tt+t;r`CH AN,ICAL FUL' Int-CiQ4i-421 (343 sib-%) f C`1`f2Ft;.rf t.'i F 1 jI= eta �)� $131.61 Pt.UMBr.NG Fa 101-000419-000 $ t621 Ai 5YRONG t6 OTICy'R F.U. • - REST) 101-OW2 1 -ti O $20.05 GRAWN•C.I+E ;f3E t [3-42A-oIi14 920.00 fAR.'1' IN PUBLICF:f',LACM3 - RLk'SIU 70 1 -XXII-255-WO $233.1.4 r)T VFMGP0R AMPACT FEE Sftji-'ro1^.tii1 Col.^tsutuCnowANU nAm CHECK .IwEM PREE-PAI•D KESS A. RECEIPT DATE BY DATE FINALED INSPECTOR INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Underground Ducts Forms & Footings �(o— Q 4 Ducts 1101, Slab Grade ©—/! Return Air Steel Combustion Air Roof Deck Exhaust Fans O.K. to Wrap Framing F.A.U. Compressor Insulation Vents Fireplace P.L. Grills Fireplace T.O. Fans 8 Controls Party Wall Insulation Condensate Lines Party Wall Firewall Exterior Lath Z Drywall - Int. Lath =��t� 6'• _ 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 Water Piping` p� / Heater Final Plumbing Final Plumbing Top Out Equipment Enclosure Shower Pans O.K for Finish Plaster Sewer Lateral Sewer Connection •6 Pool Cover Encapsulation Gas Piping Gas Test Appliances Final 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) 0