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0307-284 (PLBG)LICENSED CONTRACTOR DECLARATION I hereby affirm under penalty of perjury that I am licensed under pr&sions,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 Date Signature of Contractor OWNER -BUILDER DECLARATION • ifJ?' 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 `.t:. „gate u5 Signature of Owner C a.�. <..5.�.c:µ4 ,t .�a.,�,.a'...• 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, forthe 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 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 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 note 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 2 r° 'Signature (Owner/Agent) .�•..:e?�a•cs h "`' Date BUILDING PERMIT. PERM'®���uAi DATE VALUATION LOT" TRACT 'JOB SITE ADDRESS m�.,'S L�rii:1�FA 5�.2'�:dW APN OWNER CONTRACTOR / DESIGNER / EN (NEER e3.210AVEM".)& VALLEX) LA QUIN T?t 92253 USE OF PERMIT VAIzt1ul :tlON �. .t':y L.S I. "M NFRID COST Or c(IMSIRUCnOIN !W.M. JUL 212003 CITY OF La+ LiUINTA FINANCE DEPT.- WYEAKY".'AL AM PLM CfrS:,E �3E3.z3L+ BOB . '.'t'_wk'.', EI .t i�HS $D100 Y v� . r„T�c+ ,L' ll 2.:.t S F+ a.5P.6S,.A� .0 .Y:nF:J1./ 'iI NOW NIXI100 RECEIPT DATE '�A BY f.� , ' DATE FINALED INSPECTOR INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Underground Ducts Forms & Footings Ducts Slab 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 & 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 Plbg. Test Final I Gas Piping PLUMBING APPROVALS Gas rest 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 Utility Notice (Perm) i OWNER / BUILDER INFORMATION Dear Property Owner: An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified. For your protection you should be aware that as "Owner/ Builder" you are the responsible party of record on such a permit. Building permits are not required to be signed by property owners unless they are personally performing their own work. If your work is being performed by someone other than yourself, you may protect yourself from possible liability if that person applies for the proper permit in his or her name. Contractors are required by law to be licensed and bonded by the State of California and to have a business license from the City or County. They are also required by lawto put their license number on all permits -for which they apply. If you plan to do your own work, with the exception of variuus trades that you plan to subcontract, you should be aware of the following information for your benefit and protection: If you employ or otherwise engage any persons other than your immediate family, and the work (including materials and other costs) is $200.00 or more for the entire project; and such persons are not licensed as contractors.or. subcontractors, then you may be an employer. 3 #. ,If you_are an employer you must register with the State and Federal Government as an employer -and you are subject to several obligations including State and Fedeial`income tai dviihh-6fd`ing. federal=social= t { . r. �-. ^'J�ti� ".*.9G�lw.+')'."�.�z �`. c./ 4 a•.�*aT�l.:.:T�i. n .� . . .. �rv�n SYS^ +tl*���i��.,M'1^Tv':F.•l�i.+i=-. '(�r::..:��n.c� ''�SPfi'!�I��Jf^,",�'S a`•Y?��f:-'.��' tit'i„i.N.4%.._`.ir�"fJ.id'' .:.h ,eb:?y-4 COACHELLA VALLEY WATER DISTRICT CASH RECEIPT DETAIL 9.6923[ 1 /'� �� / � / = �. �. � "}jJ� Wil' • �-/ _ j•�+6s JQ� ! „'"'i ' i...�'� %v' ._i Received From Address:T "���� L.tr��t l�'L'�� i�r _�'�G`� la •Ci ;!` f� a' a ( Account No.7� ` "T' �- • !i'• Lots) Tract Service Address a ^� L L A.'C �C G c� Sr2 E t..) G.A. Code F ❑ Meter(s) $ ` ❑ Service(s) , ❑ Backflow(s) .j ❑ House Laterals) l E: ❑ DetectorCheck(s) i ❑ Meter Surcharge fj i-. Q'Sanitation Capacity Charge r'%r �!-� ��!'' P.� ✓.� ��, jT J „� ❑ .W.S.B.F.C. '.I ❑ Temporary Construction Meter ❑ Turn on Charge ❑ Uncollected Account - Name ❑ Inspection Fee - Tract - l: c Fee - 0 Plan Check Fees Water / Sewer - ' ,II Tract - J ❑ Bond Payment - A.D. - Bond i Assmt. j` ❑ Customer Deposit fv ❑ Other /� • TOTAL $ Remarks: �G.%TlG11 �)L,�c i A J r Wo A�/_ f� pcaPY to: � ��%:�) 7 �.:• f :A. Cash Water Service. t' Check I x,.•. :t;..„' Cashier • Money t Order CVWD-438 (11/89).