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0303-301 (BLCK)LICENSED CONTRACTOR DECLARATION I hereby affirm under penalty ofdperjury 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 rt. 40934. r an0/03 0 _- e'• �y -� Signature of Cont act r � '�`" � j �M ` *f +✓ 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. (�) 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: Cartier N1i'ii'!ONAL ON F' 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 toIbecome'subject to the workers' compensation laws of ;California, and agree that if I should become subjectio the workers' compensation provisions of Sectlon�3700•of the Labor + t e4, *ri t Code] I sha Udirthwith comply with thoseprovisions ,-Dates J<�"' Applicant-.✓ er' X' 7 f 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 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 -me ntioned'p.ropj rty�for inspection purposes. �'')l. � 1 , V,rfi ,,�, Signature (Ower/Agent)"# �� � �' �" 'Date BUILDING PERMIT PERM0303-3101 3L3t3 i DATE VALUATION ",237 LOT 162 TRACTJOB SITE ADDRESS 60.414 ]C�.YI ,�F:1"d C'OUKT APN OWNER CONTRACTOR/ DESIGNER / EN (NEER SHEA HMW ©. 81.260 AirBNUE 62 81.2610 A , .62 LA QUfNTA CA 92253 TnM? 9,. L CA, 92883 (909)833,8996 MVT 6876 USE OF PERMIT AJA LAI 0- :�NfSSI tt !1l. SxA: 1,Ar 4 9..L:l.XIENLr4Lf VorAL. SYSTM PER CDD APPROVED PLsIM FT. WALL 23 ,00 LF 4 Apr, WALL, 1.1i, UI TED COS Or, CONSM M' '.0N 8,232,00 p�i'.t"rr FEW Ind aU .R".ri' CONS'1'R W 014 FE 101.000.418.000 SSp�.tN2 D Q p AVP FRX 0 3.2 03 CITY OF Lao QUIN 5 FINANCE DEPT. f IffL 3-TOT.AL CON&R-MMON AUD PLAN CMWT,� $'1 nano UN M -PAID MIS $0.00 All RECEIPT DATE BY F L INSPEC 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 OX 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 6 3 Approval to Cover Equipment Location p.2 Underground Electric Underground Plbg. Test Final 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 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) COMMENTS: