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0111-062 (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, Aid. ITiy License is in full force and effect. License # Lic. Class Exp. Date 7776199.B 0460f2c Signature of Contractor 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 affirm7 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 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 y.A0i gS Policy No. 'WL9, C430PA319 (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 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 $100,000, in addition to the cost of compensation, damages as provided for in Section 3706 of the Labor Code, interest and attorney's fees. IMPORTANT Application is hereby made to the Director of.Building-and Safety, for a permit subject to the conditions and restrictions set forth onhis..'r, application. 1. Each person upon whose behalf this application is made & each persrgn'at whose request and for whose benefit work is performed under or pursuant to any permit issued as a result of this applicaton agrees to, & shall, indemnify & hold harmless the City of La Quinta, its officers, agents and employees. 2. Any permit issued as a result of this application becomes null and void if . work is not commenced within 180 days from date of issuance of such permit, or cessation of work for 180 days will subject permit to cancellation. I certify that I have read this application and state that the above information is correct. I agree to comply with all City, and State laws relating to the building construction, and hereby authorize representatives of this City to enter -upon the above-mentioned property for inspection purposes. t.,S-ignature (Owner/Agent) +"? Date /"'^ BUILDING PERMIT PERMIT# ; DATE VALUATION LOT TRACT, JOB SITE ,..� - - -- --- - - -- - APN �� ADDRESS OWNER CONTRACTOR /DESIGNER / EN INEER '14.9,M%9OVELY, LMEEAF ' SUM.2*220 ' 74.923 %t$O-SlELYLANE EAS' S€t1TH2420 T"film, DFIWE Off, 92260 PALL I =Wr CA 92260 t�7�pN� (:'DIN 3832 USE OF PERMIT 1 I't3LEWMLYD)W3 UHG SY70,, LX 305, SANJf A.ROSH 0. P3i;sitMIT 130ffS; NOT INC°FsUM, BLOCK WAW% MOU811A OR DRIV iWxiY MIP BOAC H, 'TM MAN MCK FU REDUCTION FOR MkJI.'t'IPLX MSUr`f,ACZ OF SAME 1'tAN TYPE C'U3`�'0M CONSTRUCTION 31741t6919F FORCHIPla110 324;00111''0, 0Abtl'w(MCAi;•',1rt aRT 936,00 Z,01 ESFI NAM C0�` OF COMM�1�'d10H z3l%wav �•yr±¢1,,yygg�����yy�7•,,yyaa�� ��;ry;� �}q-{p�,� T.77.8'.'S.IfgG(S'X91,syA.y.q�,:/S�gR'gafTyE�Q,tl.I�Yy'�,Y. -t����1x•L• y (p -y rty JgAn E yy�'+1 �v- 13+1.16 i�1•e t',ihYt�f ,i'Ailw A J utl �A"'TI -iiVt+ �Rd•)l oo PLAN C ECC PEN101 _000-439-3 18 $r'4i..w Ag9.°i+"�'�ANICAL .FEE, 101-000-421-000 -000 S"I" ELRC"f',RICALFBIP R(! -000-420-000 ($f"19.96 t''LUM1140 FEE 101-000.419.003' $1.60.00 S9'1:UNC1 MOTION PEE - PES ID 101-000-243-000 531.06 'GRADWO :VIVE 101-E100423-000 910.00 1w.ilcT fpkm $j,Q. 7.00 AAT M P0812C P1 CFS - RFzl1i' 270-00-445,000 f rs-39 v .lb_ I M.fa4. Z:C?� STRUC4TIOV AND2?} ' is 1 ;Cas TU,S2 4.20 LEX113 PRE PAU) FM S0100 nFc 03 2001 CIT9' ®F LA QUftleamWr414 •• RE C w TE BY DAT I LED INS OR fa.. S r ! 2 INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Underground Ducts Forms & Footings Ducts Slab Grade /��! pL G/,P�L- Return Air Steel _ _ Combustion Air Roof Deck a 6 Exhaust Fans O.K. to Wrap Framing _ _ V L_pa" F.A.U. Compressor Insulation 1a Vents Fireplace P.L. Grills Fireplace T.O. Fans &Controls Party Wall Insulation Condensate Lines Party Wall Firewall Exterior Lath / Drywall -Int. Lath Final i 3 �j iz Final -_ POOLS - SPAS BLOCKWALL APPROVALS 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 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 6 Utility Notice (Perm)