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0203-414 (RPL)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 656128 C 5 3 HIC `'A, I V/ 3 1 /.2. t Date' Signature of Contractor—7 fid`•` 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). ( ) 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. 4vy) 1 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 S'F.�2`Pl�. (>rJi�iPRMIATI Policy No. 446D©�6I S -p1 (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, l shall forthwith comply with those provisions. Date: a Applicant }� el ,escxe 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, damagesasprovided for in Section 3706'fV of the Labor Code, interest and attorney's fees. IMPORTANT Application is hereby made to the Director of Building and Safetytl, 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 1.80 days will subject permit to cancellation. I certify that I have read this application and state that the above information is s 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 propeQfor inspection,Ypurposes. J r a Si nature (Owner/Aent+�f b Date • �` '' CN BUILDING PERMIT - PERMIT// • , '� �► DATE >y VALUkT.e ION -, 1� LOT ` ` TRACT33 qqqq tis JOB SITE APN ADDRESS 514MS'AaN EDFOO,T OWNER CONTRACTOR /DESIGNER/ EN INEER g�1�,7 �7 p����E y� 1, ��yr d���t a�;�LB�,�• y p d� Lb' NO yA•'.AfV k'S.GA;�LJKI[ CV11'.iW lUNMES, JI��'kC �• A� y�t���13�]� ` y�,,+lry,•1 P� p �y �Ay h,[ �, 4:r?L O RWU� Yt, OLZ 4 i� KI �,(.ol! �,vcm, co .2,S?I0 F_ WA1::iC -Moo' AVE. 0100 , 74725 3010; RDIE, STME M ' SC'OXT7'117C9 l..A 9,2025 PALM 7.3E.VT'R.`.i` CA W260 C6O]3 t?v1.9000 M44 00355 USE OF PERMIT POOL e3;RO `sl?A, itSQ4 AV31 13I*54&199. ,,;ZR J*'7..A UR.K .AI.��.il.?��Sl��sf RI1�R'S SHALL BE IN l�l,� 0 taflr0� 1 O p°�t.1 P1�� iii. 1'R3SRU,C`1'ION, AX0016. L1Q1,I1PMXH d' I%L•1C`,L45q`r1VZ i\f0T INCLUDED Px4 I'EIt.IAIT. FO::�:.t�AIL'JOR,SIRA 12 �'D COST K��° fat�t�'vi'���.�J'�.�' t3T�' ;��4813`��t�.l Lv��� Y yam. est f �'(yip-y.�'T�7iy�Isp"�2' 1.9ZL1[.c7d t..N, 1D J3.AG 9RJ2i,l.F.YL.1i4:'i.b PLM CM.U. FHE 101-060-439-31.8 9,15-11110. CONS'MUCT ION d+"tIM $734100 MECHANICAL VIKE -- POOL 1,01-000-4-21-000 $74,00 ELECTRIC>,hE PEE --POOL .1,01-000.420-000 PLtrMMING Fiv:R"r POOL 101.000.419k-000 $77,00 14 APR 012002 .` CffY0FLAQ1 ,•• :00TT .00A$ 3`s`'1UC_110k1'AW131YCJXCT3F4X -$012.10 FINANCE I.E.93 PRE +AX FM RECEIPT DATE BY D INA INSPECTO Rp. 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 Gas Piping PLUMBING APPROVALS Gas Test Electric Final Waste Lines Heater Final Water Piping Plumbing Final Plumbing Top Out Equipment Enclosure Sjiower Pans O.K. for Finish Plaster Sewer Lateral Pool Cover Sewer Connection Encapsulat°or Gas Piping X Gas Test Appliances -1—S-4 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)