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0010-224 (PLBG)N r LICENSED CONTRACTOR DECLARATION I herebyaffirmunder penalty of perjury that I am licensed under provisions of Chapter.9 (commencing with Section 7000) of Division 3 of the Business and Profess.lonaliCode, and my License is in full force and effect. License #or- Llc. Class Exp. Date AD TlTe� 1 12r, y©ate Signature of Contractor's -a W OWNER -BUILDER DECLARATION I hereby affirm under penalty of perjury that I am exempt from the Contractor's License Law for the following reason: ( ) 1, 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 ei qusively 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 it I hereby affirm under penalty of perjury one of the following declarations' ( )It 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 S,Aion 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. (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 totheworkers' compensation provisions of Se tion 3700 of the Labor Pf fose, I halcrthwith comply-With=those provisions. f Date: -+ rl c Applicant �___::^ ""_-• ''`--�' i �• 7 , Warning: Failure to secure Workers' Compensation 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, indemnity & 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. ignature (Owner/Agent Dated �'t BUILDING PERMIT PERMTN DATE VALUATION LOT TRACT JOB SITE APN ADDRESS '- OWNER CONTRACTOR/DESIGNER/EN (NEER .Cis.A4A.G J all MLOo,itl LWal ilYJ.C'�tJl..q . A�4.. 743 .�IYCAMORZ AVE #4 74-990 JONI DM'VV, Vi d' 2-;D 'a"►3 Aman CA 90038 Pte. r'. U D&I i Y' :CA 92260 ' (766)340.2726 CBL* 2526 USE OF PERMIT SEPTIC AJ9 A1wiDON - SMER CM11NECT f V Aim ATION 3,pQi1. 1 L3 ISMAIRD CONST OF CdaMMIC'ffON' 110W.00 PLUMBING H12 .10) -I; 00.419eS3 O 09100 e i t 91.7.}3-T(W AL C"09S`MVIL",`iION AND PLANKIMCK $30.00 Z . PRE-PiAI } p' • S0.00 1701AL PYAOM FEES DUE MAN RECEIPT . DATE Bl'DATEFINALED l INSPECTOR J INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Bi FormsR& Footings Underground Ducts Ducts Slab Grade Return Air Steel' Combustion Air Roof Deck ExhaustFans O.K. to Wrap F.A.U. Framing I 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 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 / Sewer Connection Pool Cover Encapsulation Gas Piping 111 Gas Test Appliances Final Final Utility Notice (Gas) b�p8 l�j`7 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: ! iiisk� .4t+:♦-%•-w+.�, a+n'h•,. ry - i•,a -„�,. ,-7il,,rwa�• y� x'ae, i- . • rab..^ 4 \: �v 1x rr j . .: d r'rCa F> :ts �:.s . ' Vs.. ,. , , COACHELLA VALLEY,yyyyppTER DISTRICT` r �x + r tC A. AU tir hw qro r?L u r r r� M yast`j#..T':'+ .Y�+1.,4•�r }d ` •Li ..F 7.._.{ ';,.k off' CASH RECEI DETAILA'•�`f.- k`'`^'y'; r sr 'J-71wr _*sV - '"t+v„L t .i \,�rR v� ..+' •x %P j� C er. r ti i!�� 1., ` Stir p x I •y r . 4,3 u�° y> f+ ` s? 9t p908IV@d F•.�m' 1t 0 ,'t 4iru;k.\i,,•r' y�e�(t y 4 . .e('er;,`'"'h *�'+- . '�{.!'ti-.e 1 `*i:'�i.:J .i e. p, r I�� .. `: `' >Address , t t L v S` f { J Atti c w" xi','-: !' @ d O. �J;�,.a �' �.'T �1.�'r•LOZ(S�r r - �V b r I3 �Cr i7 ;.`.TfaCf "'3. Account No.` v g z,r. x .- ti�.r -NO «� -r^ •r � ��� fir. fr �i E? �l° ,� G.A. 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