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0109-277 (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 and Professionals Code,.and my License is in full force and effect. License # iLic. Class Exp. Date 114188 1 Date Signature of Contractor's 1 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 O.OL )1»t'T' iCiC.1s 11d+�, Policy No: J (This section need not be completed if the permit valuation is for $100.00`0_ r,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 toahe.._ 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 provisions. Date: .^ ^' > , Applicant ^., y,, '•- . Warning: Failure to secure Workers' Compensation coverageis 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. t. 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 4o 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. �r,,% Signature (Owner/Agent) ­_l"r1t1 J`'<i Date BUILDING PERMIT PERMT# 0409-277 DATE VALUATION LOT TRACT �f39 3 51 24V"- 3 // / JOB SITEt�y�y•`1 ;�v�•y�y�y� q;�•�e ADDRESS [�.,t a� GA f}✓YS�C A4Flf� �i K WA.Y APN -011 - OWNER CONTRACTOR / DESIGNER / ENGINEER t".:WW,RY CRdaWFIL COMMURAIES (immUr CRUINE , COMMINUTES 15; 5 so, 111,e y =r, 1Z 4200 l5mYo, zV. S'Cimr,, um x) 34W RBIRR,4 MM CA 92408 SA14 BERNARDINO CA 92408 (9%)pm.6m M. 2,120, USE OF PERMIT POb^ LAPA OR DRIV OWy,rtA�nYa'' APPROACH, 76'�01•'.LAW CHECK VWX REDUCTION 'Mft 1iYjU JflC r? OF NaFit711& P_"yH i"SiP , TRACT tr'f.3NS"i'Y'CUCT1014 t500.01) OF kO1".:k;;TATIO X3•.08 SIP O,A,RAWWCARPOWY 412,001SF - 'LATED 0011.ff O •p� �� � p yr�"g' p x�,g t�:y�+',�:�y�'3'1 iia A 1+1 CHW-9:.1171ls �h.L2;3°.Cj`RJC�a+4t3�yo��pTy " 1431-�ryJlll�Ri-q2� � tyaq pfl©q?.,ttrtl, `€'rl?:ONOMOTI4 �N FEE RM- 0 101 -WO -241-000 p lD3vN531OPF1t1 J'JAPAXT 3?CI F, 'tYtl. ANPi" t°HW- K V2947.79 LESS, YRE41AMPEMP $0,00 AM I PUT, NOW :1 Q� LA O'U1%'rA Cid CPT. RECEIPT DATE BY DATE F ALE INSPECTOR INSPECTION �E�:Q�D OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set BackslZl:� Forms & Footings Underground Ducts DuctsSlab [ Grade Return Air Steal Combustion Air Roof Deck�&Z ��'. O6 oI Exhaust Fans O.K. to Wrap — (J — F.A.U. Framing Compressor — — Insulation 3 �p >, _ Vents Fireplace P.L. Grills Fireplace T.O. Fans & Controls Party Wall Insulation Condensate Lines Party Wali Firemll Exterior Lath Drywall - Int. Lath Final Final ��Z ��— POOLS - SPAS SLOCKWALL APPROVALS steel Set Backs Eli: p -band Footings Main Dr�din" Bond Beam Approval o Cover Equipment Location Underground Electric Underground Plbg. Test Final Gas Piping PLUVvq01HG APPROVALS Gas Test Electric Final Waste Lines �U df _ Heater Final Water Piping (l Plumbing Final Plumbing Top Out �5 L S Equipment Enclosure Shower Pans O.K. for Finish Plaster Suver Lateral _ /� Pool Cover Sir Connection y - . Z Encapsulation Gas Piping Gas Test _ Appliances Final COMMENTS: Finel Utility Notice (Gas) ELECTRICAL APPROVALS Temp. Power Pole Underground Conduit Rough Wiring Low Voltage Wiring Fixtures Main Service Sub Panels Exterior Receptacles _ s G.F.I. _ Smoke Detectors Temp. Use of Power Final — Utility Notice (Perm) 3 - _ Z