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9810-073 (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 # Lic. Class Exp. Date 64064:5 _ :, ; ' 01.30100 Date Signature of ContractorK. 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 riot 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 3.700 of the Labor Code, for the performance of the work for which this permit is issued. ,/C, )t 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. • ST ATE, tlNlJ 03-4-4p44230 (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, J 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 Code, I shall forthwith comply with those provisions. Date: Applicant Warning: Failure to secure Workers' Compensation coverage is unlawful and shall subject an employer to criminal penalties and civil fines up to $100,000, in addition to the cost of compensation, damages as provided for in Section 3706 of the Labor Code, interest and attorney's fees. �a? IMPORTANT Application is hereby made to the Director of Building and Safety v' for a permit subject to the conditions and restrictions set forth on his application. 1. Each person upon whose behalf this application is made & each person at whose request and for whose benefit work is performed under or pursuant to any permit.issued as a result of this applicaton agrees to, & shall, indemnify & hold harmless the City of La Quinta, .its officers, agents and employees. 2. Any permit issued as a result of this application becomes null and void if work is not commenced within 180 days from date of issuance of such permit, or cessation of work for 180 days will subject permit to cancellation. I certify that I have read this application and state that the above information is correct. I agree to comply with all City, and State laws relating to the building construction, and hereby authorize representatives of this City to enter upon; .' the above-mentioned property for inspection purposes. Signature (Owner/Agent) �-�" Date J•?140 PERMIT#' °°NTR°`# BUILDING PERMIT �y� DATE VALUATION RiUa3. ,748 " LOT 34 TRACT 20,Lyp r JOB SITE 79-2.`9 T ®.R'O A APN 769-��ff►li 4 ��D`T ADDRESS I OWNER CONTRACTOR/DESIGNER/ENGINEER PO J30 810 l 14:25:, i��Jl . leSliY 1GkIV • ILA QUI -9,17A CA 42253 PHOENIX .AZ 8V. 34 (602)2.57-1656 COU Q�0 USE OF PERMIT NGLE' 'FAM f LY DWELLING SATS, :LOQ' # 34, 'PLAN 3GR, PEtUflT DOES NOT .:1`NCLUDE BLOC K WALL OR POOL. 1?F.;i MIT FEE RWUCW.) J8Y 7_91a FOR .MU;i .'1'INLE ISSUANCE 0F SAM& PLAN '[`1TE, CiJS'1' m C 6JxS"1,R0C '1O1q. 2,8_13-fK'e s PORCH/PATIO 130.00 SE GAl'tAGWC tlltf'CWf 57€4.00 SP 'ESTINIATUD41COST OF CONSTIMMON. '231,148,50 P—OR "$.T FRE SUMMARY CONSTRM 10N FFX 101-000 4if OOO S1,10.50 PLAN C-'`f1ECK FLIT, 10,1 -M(? -419-318, 3t��fi. �E► AEC'13.I`>tiIvvTCAL FEE 05.00 EI-ECTR.TCAL L'IEL 1t3i.-u(it3-r;" 0.000 $).6i3. 7 PLIJACk fNo AM 101-000-419-000 SIV ONO Nt► )T!Q'N FEE - RKltil0 101.0S'0-241.000 i[i�13�,f1+dCi 11 101.-000-421000 iWitM'7'`fW�CTftt 814 ' 225-000,443-34 $5.220.44 AR'T' INPCfk LIC PLAC438 -10STL" 701 -000 -253 -OW $3.44.37. "l 't`t1AL G`{O1►j4T1`l, '101 AAI? �L,1A:.N C:�1sC:1C PK.r g7,;3Etb,90 LESS Pl.:E-MD FEES $©:� OCT 14 1998 TOTAL :PM111T F CV-% MfC' NOW � p Q ;I r 7' �a RECEIPT , ' DATE 1 0 DATE FINALED INSPECTOR a' '■ _ • [0011 N • OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs — Underground Ducts Forms & Footings t Ducts Slab Grade A, 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 Electric Bond Footings Main Drain Bond Beam Approval to Cover Equipment Location Underground Electric Underground Plbg. Test Final I Gas Piping PLUMBING APPROVALS ot Gas Test Electric Final Waste Lines .rte .. 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 r Final Utility Notice (Perm) COMMENTS: