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0207-029 (RPL),.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 651503 B C27 07/33/2( Date _-7- /' Signature of Contractor ; OWNER -BUILDER DECLARATION I hereby affirm under penalty of perjury that I am exempf�from the Contractor's License Law for the following reason: I. ( ) 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). r ( ) 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: () 1 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. ( ) 1 have -arid will maintain workers' compensation insurance, as required by Section 3700•'of the-La66r Cbde,'.for the performance of the work for which this permit is issued. My workers' compensation insurance carrier & policy no. are: Carrier MID-6EITURY Policy No. AOI N-69-5'7 (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 5o.,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 370O�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 on Fjis s application. 1. Each person upon whose behalf this application Js made & each persgn::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 propertyfor.inspection purposes. Signature (Owner/Agent) f r Date ryUIL-DING PERMIT PERMIT# :Clay 4? DATE 'VALUATION" LOT�pd >( 'TRACT JOB SITE ,Kt,•,� ADDRESSi^in.J.e°'�J�% APN a OWNER CONTRACTOR/DESIGNER/EN (NEER TUiBRM13 M U40, J),E3FR`C'fIRS CtNSiWTMON 74-9233OWL1JIM ryA.Sp.rJIaM"220 4.155E AWcpSJ9E PAIN DW#- 2T CA 92260 nM!J YDA DvIM CA .42201 (760}360-4400 Mh 3046 USE OF PERMIT €LIDO' NPA, AYA#'i.NSMARNEAS URAL L HE IN PLACE PRIOR TO .r1�j�1�►.�.aT��t 1A1�Pt���� PfOOLe.. NIVOR,.5PA I's 8sC7y:L.rLLV 4efi b.iJ.0 'ii ai7Pi, M1a�lo 4rhAI.Ssmuc.L:}0+7i'Z 0 19100020 �'�p' qij � P�.4►suiva���',V WhOAARA P;.•AN Ci1''Y, REE 101 -MG -439-316 G-439-316 $12910 CONSTRUCTION Wr. 101-000-41"150 V618.00 lvllr,;(.:&1ANWAI.,k"1AI -- POOL, 101.000-11'21-00 4200 IFILWITRICAL F" 1.1`1001, 101-000410-000 V&atl PLUMSINVI RF — N130 -L 101 -000-419-000 $27,00 �?�-'1WA1:, CONI` 'i.+.L€LM©NAA' D PLAN CTIFA- : $422.10 PRE—PAID WHO $0,03 _IMIS JUL 2 o CITY OF LAQUIMTA EINANCEDEPT DATE I' By DATE FINALED INSPECTOR INSPECTION RECORD OPERATION I DATE I INSPECTOR OPERATION I DATE I INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Underground Ducts Forms & Footings Ducts Stab 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 8 Controls Party Wall Insulation Condensate Lines Party Wall 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 PIN. Test .JFinal Gas Piping PLUMBING APPROVALS Gas Test Electric Final j •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)