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0204-115 (MISC)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 # Lic. Class Exp. Date 73409' AB 1110 �4 U4h� 3/31/03 Date "'`"'i�' Signature of Coniractor-4gh �y c 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. �(..LI 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 ZVOILIC►°I AMERICAN Policy No. W00412096-03 (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,Labor Codey, , I shall forthwith comply, those pro"bisions. s` .� Date: t'=� ���� ApPlcarit-^~ �-�/�r� :�F 4 �» •• Warning: Failure to secure Workers' Compensation coverage is unlawful and shall subject an employer to criminal penalties and civil fines.G'p\to $100,000, in addition to the cost of compensation, damages as provided for in Section 3706 of the Labor Code, interest and attorney's fees. IMPORTANT Application is hereby made to the Director of Building and Safety for a permit.'subject to the conditions and restrictions set forth on his application. 1. Each person upon whose behalf this application is made & each person at whose request and for whose benefit work is performed under or pursuant to any permit issued as a result of this applicaton agrees to, & shall, indemnify & hold harmless the City of La Quinta, its officers, agents and employees. 2.'Any,permit issued as a result of this application becomes null and void if work.is'not commenced;.Within;180 days from date of issuance of such erTit, or cessation; of work. for 180. days will subject permit to cancellation. I certify that 1=haye'read this'application and state that the above information is correct. I.agTq. to,corriply with all City, and State laws relating to the building `-c6nstruction,.and hereby''authorize representatives of this City to enter upon 'the:above=mentioned property for inspection purposes. `",Signature (Owner/Ag t) _ i/ !� ' Date BUILDING PERMIT PERMIT#ky �+ DATE 'VALUATION s /ipA LOT � i� " TRACT 28960 JOB SITE APN OWNER (M IIk7l;ii�Y.h+�.,�` 2280 W )LON CIPICiL. suffri 2.50 CORONA ICA 0 D 7-0 USE OF PERMIT CONTRACTOR/DESIGNER/ 22,80 WARDW 'W 'CORONA, CA 01720 (VQ�)2,794000 MUt X76-!'..,= SUPPL.EMSM'VAL. PERMIT 1-0 9 0106.2Cr4,mTfLZCTlNO Ck ORIENTATIOM OP 03AR-AGE PROM RIOKf TO LEP? WD? ESTDA&TED G09' OF CONFI tSYMIO.E1i' MWIT YU 91—TAMARY A.e:#4�%'IeYll�i3'1�%���?F.$%�I'1.''�'3?'� ISbi�t,?�7t3•R2�wf)f1t? - $�>�i! D � D -- MAY 0 3 7��1 CITYOFLAOmur. dy. +Bm°I'tYXAL CO�€'4T:�;U TIO A1�'.%� I*[ -,A ' 0MCK `S':` WAIS P3iRMU S 1)UE .]�O RECEIPT DATE BY DATE FINALkDECTOR F' e :fit r& 0.£t0 $4.50 $0,00 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 Wali Insulation Condensate Lines Party Wail 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 PI . 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 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)