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9902-161 (DEMO)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 l.t3l'?ii 13 _,Date .� � ! A r} Signature of Contractor OWNER -BUILDER DECLARATION I hereby affirm under penalty of perjury that 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 their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business & Professionals Code). (•) ' I, as uwner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business & Professionals Code). () Ilam 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. 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 carder & policy no. are: Carrier Policy No. CAL 1KDE MKt'1 V INS 14S047u6IM (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, I shall forthwith comply with those provisions. bate:-- ' Applicant 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. ° A. 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 Cityof 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 6orrect.'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 property for inspection purposes. �Slg' nature (Owner/Agent) �'"�'^'='�' Date PERMIT # BUILDING PERMIT "02, 161 DATE 2tZ6199 VALUATION � � LOT TRACTJOB ' ADDRESS 4.3'-576 in�A,i14 4i>;•��€�N SMUT APN OWNER CONTRACTOR/DESIGNER/ENGINEER SALO.K'iRUST 1 -;RIS -1- L t~i' MMUC:T.ION , N.C. 42-335 WA[. HiNcii:©N S7'REFT sum:% 1: 33c 73929 LAiZREA. ##1. BALM DESEWU CA- 92711 PALM DESERT CA 922,60 (160),346-4061 011A 5333 USE OF PERMIT D1~sviO1...iS14 .QX3S':t' 111 STRU fi(!RE ; .: f ' I &MIRK, or,!! 199& `'ITY ® LA '�dUHNTA . ESTIALIM::2D CaS 01%' I:*A10L1T'!( ON .f*i?k: 1.0.1-000423-000 iti,iJ!} SUR—Tl.a`4'A1. l`'•ONS!'RI, C 9`E'(aN IXINO PLAE4T CHECK TOTAL PERMIT POWN AR47, NOW S45-00 RECEIPT DATE Y DATE FINALED INSPECTOR _;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 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 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: