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9905-258 (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 6372 J-2 B 02129r.,01 Date ' Signature of Contractor �!Vo'-�, 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 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 3700 of the Labor Code, for the performance of the work for which this permit is issued. U-) 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. R0VAL M, Co. Or 1 VrC X157,87 (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 l should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those p ions. Dat _rc� ovls : --2Applicant .���-* - ,4 -ge-a � ✓1Narning: 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 ismade & 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 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. y� Signature (Owner/Agent) Date BUILDING PERMIT PERMIT�2� DATE VALUATION, $124X6.30 0 LOT 22 TRACT 286014, t� f Y - JOB SITE 47 �J - SVryIA(-- 8 1REST ADDRESS APN "!-U6_020 OWNER CONTRACTOR / DESIGNER / ENGINEER t::,AA1'i?LLUS ,R,F.S-IDP. +trIA'L. C0_KH iNTT1.E;,% flNC CAULLUS i BSIT)"E IIAL C".C3Nti'1`i UC 1110 5 PARK PLA!", k SUri'; 400 5 PARK PLIV,/%, SUM"' 400 - (R'VfNE CA 92614 f.Rvwu� CA 9201.4 (949)25141.00 CUP- 5022 USE OF PERMIT S,WOLE F'AMMLI' DVIrF%i.NG SM -PLAN 3A LOT 22 -1YM T i3CC814i)T 1NCUTDF. 13LOCK Wjv.LS OR P001, -PLAN Gf.4. - K PORTION OF FAR;lt.L"Ltf tG'ED 75¢Jo FOR Yl1iTC.'1'TME 13SUANMOa• SAIWE MAN'1'S.PE TRA.+ T<:tiNST'RU�.:=d'eC)N 2,097.06 SF Ci.{ RAG1MARP011T 450.00 31: ri'',1gt 41T '>17FIC SUMMARY C0143TRILI(,"VIONFEE 101-000-4111-000 $727.00 PL.AN'C'lfRCfK.FIT" 'fN—LF01R-4-19-31R INIUCHAN]CA1. FEE 101-000-421-000 566.50 UBCTJiWAL M&C lel-fid -420.01)0 $130.90 ,PLUAN18114G :FEE 101-000-419-000 5160.00 ONG MQ'1'TON to -1 -'M10110 1A.1 -11.00 -?41.-000 512.42 1,01-000-423-000 320.00 I`1vr.1w1k 11A1 UC" r(JRE FM W -M-443-342 $Z760.46 ART fN PILI UC'..KAC ES - R1,S111 701-000-255.000 S6034 %JT3-r(Y A1.4`.C. "N"51'.RUC.`�'3.t?l+ AND �l,Asi�3�ctH CHECK �4,{Q11.4ry2� '-:`1�I. '.J. IrLNS .L'•P.r�.f.0 FEES 9 • . • j '1'C�T.A.I:: �':1�1k;'��il�' F':1;� 6)i7k iVt:iW » �93,9ti.4E JUIN U � 1999 �a u' RECEIPT �' ° ] DATE By. DATE FINALED INSPECTOR f IN( INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Underground Ducts Forms & Footings cy.0% 7, rDucts Slab Grade — 6 Return Air Steel Combustion Air Roof Deck Exhaust Fans OX to Wrap F.A.U. Framing _ S 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 Z • /y—�g % 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 Gas Test Electric Final Waste Lines db 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 _ ZS– B-© .� 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 jp, ls-ellh Utility Notice (Perm) '2 _Z _Q COMMENTS: