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9703-102 (PLBG)LICENSED CONTRACTOR DECLARATION 4'Al&,eby 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 265214 C42 :M97 ate i � ; � � ;Signature of Contractor•_ OWNER -BUILDER DECLARATIO d' 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 cafrier & 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, andagree that if, I should become subject to the workers' compensation provisions of Section 3700 of the. Labor Code, I shy I forthwith comply with t ose�prr-ve Bias. Date: :��� 7 Applicant V. �'�� Warning: Failure to secure Workers' Comper sation 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 Sectioh*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 fq the building construction, and hereby authorize representatives of this City t6enter upon the above-mentioned propertyfor inspection purposes. �innature (Owner/Agent)-' ` Date 9 -y `7 BUILDING PERMIT PERMIT# CONTROL# 9703402 4884, DATE , VALUATION, - LOT TRACT JOB SITE ADDRESS 531-217 AVENIAA DJ.t Z APN OWNER CONTRACTOR/DESIGNER/ENGINEER ^, LiT?El.., TICE, t r4Aa.+T�ji�t 53271 AVENWA. Gila Z 16819 LrITLE MORONG0 RD. - I,�1. CA, 92:253 DESE P07 .}.-1OT SPRING.' CA 52240 (619):,J2y6vs CTIL9, 386 USE OF PERMIT t'.f..8f11�t13 T >R)aYV£w t1JAA9L*V, atMT-ifd. CONNECT r VALUM10N. 1,500,00 LS A ;a"Rrt Aliff C".il:lt; SUMMARY . f21;t1IMAI'NO F -Ek SI:C4 Ut 1(11-000-419-000 SX).00 Ilk AZ;� a ��PP.E�-111D Fi::F?ti $0.00 �Q . ��'y�:mr. ����at��'g' �'��j:� aal�fl,i,•IAtci�a'' X31>.�14t . q J r-Irk RECEIPT DATE B1' " DATE FINALED. ' INSPECTOR _,t 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 BLOCKWALL APPROVALS POOLS - SPAS steel Set Backs Electric Bond Footings Main Drain Bond Beam Approval to Cover Equipment Location Underground Electric Underground P1bg. 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) YZZ 4,17 ELECTRICA APPROVALS Temp. Power Pole Underground Conduit Rough Wiring Low Vottage Wiring Fixtures Main Service Sub Panels Exterior Receptacles G.F.I. Smoke Detectors Temp. Use of Power Final Utility Notice (Perm) COMMENTS: 7 N COACHELLA VALLEY WATER DISTRICT I CASH RECEI¢ILT DETA%D M Received From: J ty Address: ? Tract m �, �� Lot(s) N LQ Account No. n � _ 1 3A Code .. SerriceAddress ❑ Meter(S) _ ,a I Q Service(s) 3 ❑ Bacimlow(s) n ❑ House Laterals) 3 0 ❑ Detector Check(s), ❑ Metersurcharge 1 � � Wtanitation Capacity Change Q N1.S.B.F.C. ❑ Temporary•Consttuction Meter 'ti""" '" T^' �'�'� lW�►(n, 'I 1 1 ❑ Tum on Charge ^ -� _0 uncol'lected Account -Name ' ❑ Inspection Fee -Tract - 1 I Fee - U Plan Check Fees Water J Sewer - Tract - 1 I8ond�--- i`-7. Bond Payment - A,D- - Assmt. Q' ❑ Customer Deposit — -- _ -J ❑ Ot"er ^ . 0 TOTAL S ,D Remarks: l�%. — (D Al .,,/ L W iter Service l�— l to. J Cash�f Cashier_ Check LLL I I — - . CYwD-432 i 1 r89) Money , . Order _.s - �. I N I •: I I