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9708-094 (PLBG)P'r Date .. t . rr _.�. t},��r.,r v-^ aj. .-„...q. ..r.,er•-V- .. ^,-.� y.. .. - � LICENSED CONTRACTOR DECLARATION,' -affirm under penalty of perjury,that I am'licensed under provislons;of%' ,9 (commencing with Section 7000) of Division 3 of the. Business and onals Code, and my.License is iiifull force,and effect. , e}# Lic;.l•Class tr/)/L: Exp. Date yk Signature of'Contractor #� ' OWNER -BUILDER DECLAR TION; a I hereby affirm under penalty of perjuy that I am ekerript from the,Contrac is ; License Law for the following reason (•) 1, as owner of the property;yor my employees with wages as their sol R. . compensation, will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business & Prof es'sionals,Code). ( ) I, as owner of:the property, am exclusively'°contracting with licensedl contractors to construct the project (Sec': 7044, Business,& Professionalsj (Code). () I am exempt under Section`};'B&P.C. for this reason r Date .'Signature of Owner WORKER'S COMPENSATION DECLARATION .I hereby affirm under penalty of perjury' -.one of the following declarations:. . ( ) s l 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 *- 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 th'e'work for which this permit is issued, 'I shall not employ any person in any manner s6 as to become subject to the workers' compensation laws of Ca'lif6mia, andragree that if I should become subject to the -,workers' compensation p'rovi tons of Section 3700 of the Labor Code, I Shall fo, hw h compl'y;With those pr vis) nns�:,., �1 Date: 2 � � Applicant.- Warnin:: Failure to secure WoZers' G�•ompensation coverage is unlawful and ;. . shall subject an employer to criminal penalties and civil fines up to $100,000; iri;` addition to•fhe cost of compensation ifdamages 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' fora permit subject to ,the conditions and restrictions set forth on his, application. - • '''2 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. / r 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 correcf:•I agree to comply with dll Cit nd State laws relating to.the..buildirig construction, and hereby authorize representatives of this City to'enter upon the above-mentioned prope y,,for Inspection purposes. 5z' -Signature (.Owner/Age Date! � • • BUIL-DING PERMIT PERMIT # - - 7j7{��� s CONTROL # :"5.7:63 DATE VALUATION j�t j¢�) LOT TRACTJOB 33 ADDRESS�.��I APN OWNER CONTRACTOR / DESIGNER / ENGINEER f AIM. I' A(I"PACY tioat�♦ S� i :,%flrrJAnE'{t,!V!� '� 3�?.i Ai,Id;'�i0�'1ii,�::.i i y -I -A R�I�I:YTA CliN 922S'A VAIAM 1,11 -UR l` ti,A 92A61 USE OF PERMIT Lc,+ ' t1!7OD 0-1.4411 CT 'Ki+fMii f r4; RF, NUMfV AR Y" P£+arlivi£ INN ).'Fh. - INIEWW I0I-000-0940) 1 ' d AND PfAN C`fi IC � t!}t►C1 ! lKA#, PERMIT ai S, 00r, tYow, $30.00 RECEIPT DATE a BY DATE FINALED INSPECTOR OPERATION DATE INSPECTOR OPERATION DATE TINSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Underground Ducts Forms & Footings Ducts Slab Grade Return Air Steel Combustion Air Roof Deck Exhaust Fans OX 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 w, , = . •.. 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 OX for Finish Plaster Sewer LateralPool Cover Sewer Connection 7 0Encapsulation 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: 91 ECONO SEWER SERVICES P.O. BOX 192 PALM DESERT, CA 92261 AM WORK ORDER OEM l/0VJ 3K0 -L/73 k/OVJ "0-//0V FAX (760) 347-4978 TOTAL MATERIALS DAT OFORDER CUSTOMER'S ORDER NO. PHONE I MEC HELPER STARTING DATE ////M�IANIC //+y-0 PI EASE PAY FROM THIS iNyntrr 3.3:. ORDER TAKEN BY �,. NO STATEMENT Will I IRF MU Fn - TAX ADDRE DATE COMPLETED ❑ DAY WORK .TOTAL AMOUNT $A / ❑ CONTRACT ❑ EXTRA CITY ❑ No onf; home` ❑ Total amount due otal billing to JOB NAME AND CATION JOB PHONE DESCRIPTION OF WORK PAYMENT TERMS NET 10 DAYS FROM DATE OF SERVICE Signature for above work: or be mailed after completion I hereby acknowledge the satisfactory completionof work of the above described work. . TOTAL MATERIALS TOTALLABOR :. ak PI EASE PAY FROM THIS iNyntrr 3.3:. �,. NO STATEMENT Will I IRF MU Fn - TAX DATE COMPLETED WORK ORDERED BY .TOTAL AMOUNT $A / ❑ No onf; home` ❑ Total amount due otal billing to Signature for above work: or be mailed after completion I hereby acknowledge the satisfactory completionof work of the above described work. .