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0312-102 (RPL)LICENSED CONTRACTOR DECLARATION I hereby affirm under penalty of that I am licensed under of PERMIT# BUILDING PERMIT IV/I— U ' L1J perjury provisions Chapter 9 (commencing with Section 7000) of Division 3 of the Business and full force .1 TRACT } DATE �` `" ` VALUATION Lor 04 L Professionals Code, and my License is in and effect. O w� LO License # Lic. Class Exp. Date JOB SITE APN r- 656 128 C53 mc C ADDRESS 6' 1--J D. 'ARM DIMN - !`LU Z r- y91/(72/3..,11� r Date "t� Signature of Contractor p� ! OWNER CONTRACTOR/DESIGNER/EN (NEER 00? J U C:) OWNER -BUILDER DECLARATION SHE& HOAG+.S CAUFORMA & [K)AX CD:)P NZAYT C( W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's 81 "26MV:Bi IM 62 £6.100 AV:£':,l� M, 54 ~ a U) License Law for the followingreason: 1A UNTA C41, 928 s:i C`C3�',L"g-iMIL A CA. 92236 Z_ ( ) I, as owner of the property, or my employees with wages as their sole (76C'�398.9222 CPJ-41 00355 compensation, will do the work, and the structure is not intended or offered for USE OF PERMIT sale (Sec. 7044, Business & Professionals Code). ( ) I, as owner of the property, am exclusively contracting with licensed �,/C�2i SPA contractors to construct the project (Sec. 7044, Business & Professionalsr©(31 M Code). ( ) I am exempt under Section , B&P.C. for this reason .PIOOUSIP.A. 13 LY. S' BLOCK WALL, CJTY STANDARD. LO A[AWOW ARMERS SRAU, U TN PLACE A`!' PIM, PJ A9'! ER INSPECTION N ON Date Signature of Owner a z WORKER'S COMPENSATION DECLARATION C) Cr I hereby affirm under penalty of perjury one of the following declarations: 1�)� i,i,Q41 LF O () 1 have and will maintain a certificate of consent to self -insure for workers' X W compensation, as provided for by Section 3700 of the Labor Code, for the g«1� ��i0(OFtS'H. 17,74 1,0Z T. O � Q m performance of the work for which this permit is issued. Q U (�.)_I.have and will maintain workers' compensation insurance, as required by D� Q d Section 3700 of the Labor Code, for the performance of the work for which this insurance & rn H permit is issued. My workers' compensation carrier policy no. are: It ? a� Carrier C FliPI; C(�ii�ilP1;"fdw'• T1 Policy No. p.9G- 103-203 ESM1VI .:C7. D C(3 .' OF CONSI'�iY7(.'�:i1C,14 /�ma-yy V g )y��q.�t�Y C� ��yp,� tP� :GD.il. �rr.7J.R.0.►YA.i8RY (This section need not be completed if the permit valuation is for $100.00 or less). PLNK CHICK PEE 101-M -439-318 J ( ) I certify that in the performance of the work for which this permit is issued, CSONS'I'i7.i3L'`Pltv`N 178E 101-(Y00-418-000 $199.00 1 shall not employ any person in any manner so as to become subject to the I$AhtC�iL C1B -- POOL 101-000-421-000 b24,Cr► workers' compensation laws, of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor ELECTRICAL, FMI .> POOL 10i-OW420-000 $25-00 Code,'I s.all forthwith comply with those provisions./' i Date: ��. / + Applicant— pplicant G I& Zy�,11p�j�f1'R0 FSE -- POOL, 101.000.419.000 $i'i.0 • Warning: Failure to secure Workers' Compensatiofi 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 y �`' '� f�c� ]f y �7CJiCEN AM x O`I1i-d S-422,ifa 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 © D 1221S 11,R)UPAJD.FMS V1, 00 & 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 if2 J' € 4,)�1', , YURIM. F DUR Now $422.10 work is not commenced within 180 days from date of issuance of such DEC 1 1003 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 CITY OF LA OUI.9.rA ° correct. I agree to comply with all City, and State laws relating to the building. FINANCE ®I=P'T. construction, and hereby authorize representatives of this City to enter upon the above-mentioned property for inspection purposes. `_'A W � ` RECEIPT DATE ; � ' BY �� �• � D FINALED � �—GG INSPECTOR Signature (Owner/Agent) Date � � � w. 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 I SLOCKWALL APPROVALS POOLS - SPAS Steel Set Backs Electric Bond r Footings Main Drain _ Bond Beam Approval to Cover ; Equipment Location Underground Electric Underground Plbg. Test Final Gas Piping PLUMBING APPROVALS Gas Test Electric Final Waste Lines Heater Final Water Piping Plumbing Final Pitmbing Top Out Equipment Enclosure Shower Pans OX 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: