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0006-197 (BLCK)LICENSED CONTRACTOR DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions c ,Chapter 9.(commencing with Section 7000) of Division 3 of the Business an Professionals Code, and my License is in full force and effect. License # Lic. Class Exp. Date 7591 fi'1 C29:?21?812 Date'ignature of Contract orf�� r OWNER -BUILDER DECLARATION I hereby affirm under penalty of perjury that I am exempt from the Contractor' License Law for the following reason: ( ) I, as owner of the property, or my employees with wages as their soil compensation, will do the work, and the structure is not intended or offered fo sale (Sec. 7044, Business & Professionals Code). ( ) I, as owner of the property, am exclusively contracting with license( contractors to construct the project (Sec. 7044, Business & Professional: 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 b) Section 3700 of the Labor Code, for the performance of the work for which thi: permit is issued. My workers' compensation insurance carrier & policy no. are Carrier STAT& FUND - Policy No. C149.9.9 001,9427 (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 provisions of Section 3700 of the Laboi Code, I shall forthwith comply with those provisions. Date: i ­!r r,PI oApplicant Warning: Failure to secure Workers' Compensation coverages unlawful anc shall subject an employer to criminal penalties and civil fines uprto $100,000, it addition to the cost of compensation, damages as provided for in Section 370E 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 al whose request and for whose benefit work is performed under or pursuant tc 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 it 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. Signature (Owner/Agent) /._Y, Date t f BUILDING PERMIT PERMIT# f DATE VALUATION LOT t� 06-191 TRACT (j p9 'p�/'�` � ry g!j� V6/dn�lA uc $2,�769 M $2,369M JOB SITE ADDRESS 51_495L;a 7�3 f i1t0 ,�3 APN 76.9-1,14-024 OWNER CONTRACTOR / DESIGNER / ENGINEER LYYNDONFR.A,NZ DAILEY'S IAASONTRY C'°ON' RA(nms PO BOX 11003 81AV6 ALS MA. AVENI If PIU -M DEMKIF Cit. .92255. 11`TIO CA 9224D2 (76©): '73375 CBLVI 5565 ' USE OF PERMIT I y w`i3PPLH�3k`143'PL:RCl;h+diT TO 0001.269.RF41?i, ACE i?afe . 3(H) V1001:0N FRHOTdVf i3iil. . 5 1;3 C3AI'.iyZ:At'@VA€,i� Hi,UC ) .4~ Si7 anL..f;. 6Croj GARDlr'N WAL.L(13L OCK) 61r. WALL 26.00 111: 5 FT. WALL 130.00 LF CONSTRUCTION ME 101.000.418.000 $54,00 �W WB -TOTAL CONS"1RtTM09 AND x.TrAK C:TWK IMS PRE -PAM IT W IDTAL PEEMEIMM DUE NOW RECEIPT DATE BY , 'J DATE FINALED IINSPECTOR 213591105.0 $54,00 $0,0© X4.00 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 Footings S Electric Bond Main Drain Bond Beam la. W-0 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 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: