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9612-138 (SFD)U) C\I LLJ C') LO PZ Cr Z 0 0 LLI LL1 1-- a - U) Z C0 LO N 0 C\I 0) < CL 2 Z Lo < Cr , I_2 0 X W �: 0 _J _J _J < < bO LO Z C6 �) 0 _J F1 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 07 W41.88 Ot'atf 1� Signature of Co ntractor_��_ OWNER -BUILDER DECIfARATION I hereby affirm under penalty of 4p"erJqh(,tfiat, I am exempt from the Contractor's License Law for the following reason: ( ) 1, as owner of the property, or my employees with wages as theirsole compensation, will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business & Professionals Code). ( ) 1, 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. ki 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 Co. Policy No. 204'41(9;6 %1. (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<should become subject to the workers' compensation provisions f dc"tion 3.700 of the Labor C -de ' I shall fo� hwith comply with thoie—provisions. ate: J::�! ) 2:1 ) efL__ Applicant-"' (4-[/, m jy, `�� Warning'- Failure to seruir�'-�W�-o-rker�s;,'�C:�'c�p�ensatio-n--co—v—e—r�age is unlawful and shall subject an employer to cri'minfg�p`enaliies 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 repre , s entatives"6f this City'to enter upon th above- m ention ed property for tion -purposes. ySinnat6re (Owner/Aqent):.!� Date PERMIT CONTROL#.. BUILDING PERMIT. - '.LOT," DATE o;t VALUATION TRACT JOSSITE ADDRESS OWNER CONTRACTOR DESIGNER ENGINEER 15-15 Scl 111 0,1 SITRE-tT, VE. 9200 1355 SO. "D" STRE U, 91,78. .14MO &AN 86*WNAI�DTNO CA 92408 SANRERNARPMO CA 97A08 WIN" Wxv'UNNAGUMAR �=OCIA71VS USE OF PERMIT $A sq,PIALs�o Avs, VDPA4 E PLAN 5.1(A 11ACT CONS17RUMON) Z0710 SF PORCH)PA110 63.6) SF GA1tA0WCARP%C.1' 576.00 ST: 1 Z 'r 01 , UJAIATEDCON rNOONSTRUCTION AAA.1. X, A 124,691.40 VL A:N CUFRX RHE I r10,'W;TPV47!10W rXT XIWU11M4WAL 117Z ES 101-000-421-000 )I fXTFUCAL I,umowt FEFS, 101--000-419-Ow $167.25 r, MONOMOTtON QW8) III I _4100 -IM 400 $12,47 IC- R. ADNNG 101 �M_4231_000 $W.00 ART IN PC IRLIC PLA10E.9 (W.38) 70 -1 -000 -255 -AW $61.73 IRMB-11,K)TAL CONCII.MaJ M11,019 1WD PLAN C14 F*CK $4,601124 LESS -.1PAYD VE VS PRL E $0.00 T0TA1, PERMIT FEWS 10.3e. NOW 194,601,24 DIE REEEiPT DATE DATEFINALED JINSPECTOR INSPECTION RECORD OPERATION I DATE I INSPECTOR OPERATION I DATE —TINSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs / / � If Underground Ducts Forms & Footings Ducts Slab Grade Return Air Steel Combustion Air Roof Deck Exhaust Fans O.K to Wrap F.A.U. Framing 00" 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 Approval to Cover Equipment Location Underground Electric Underground PIbg. Test Final Gas Piping PLUMBING APPROVALS Gas Test Electric Final Waste Lines Heater Final Water Piping Plumbing Final Plumbing Top Out Equipment Enclosure ShowerPans 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) /Z/_ COMMENTS: