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0202-317 (MISC)�'• . ` :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 r 4SZ623 - • i t 0 4'2011038 F 13013: Date Signature of Contractor OWNER -BUILDER DECLARATION I hereby affirm under penalty of perjury that I am exempt from the Contractor's License taw 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). (�,L) I, asowner of the property; am exclusively contracting with licensed contractors to construct the _ project (Sec. 7044,' Business & Professionals Code). O ;1 am exempt under Section B&P.C. for this reason -t Date z .2 0'L ' Signature of Owne�4n. 1.9d U 41, , r •' WORKER'S COMPENSATION DECLAf�RATION I hereby affirm under penalty of perjury one of the following declarations: O 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. 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 UT pp.r,y��yy pp ppyy' 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' corn pensation,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. / _ Date'_° • _a ..? • ©L APPlicant /'e 1 A. ,i 1-?f1V M,/, _ -^,',� 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, interestand 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, r & hold harmless the City of La Quinta, its officers, agents and employee�.i 2. Any permit issued as a result of this application becomes null and void lif Work is not commenced within 180 days from date of issuance of suc� { permit, or cessation of.work for 180 days will subject permit to cancellatio i I certify that I have read this application and state that the above information ' correct. I agree to comply with all City, and State laws relating to the buildin , construction, and hereby authorize representatives of this City,•to enter upon, the above- menti oned,property for inspection purposes. nature (Owner/A ent i ar.:. 7G �i _r..:_ y Date)- 2 c:) 2._ Z BUILDINGwPERMIT "' PERMIT#: DATE VALUATION LOT 0702-317 TRACT / 900 JOB SITE APN ADDRESS 47-555 -555 `-pIG'TON x.R¢CrT' `iVT^4/�l'i 'Aro OWNER CONTRACTOR / DESIGNER / EN (NEER LA A Q V SN A, X•i. d'4RIM.— 1701A"kJJIMIO�f .AE:.XO•t,af.47 W J K, RX. .P() DOX 11,77 600 EUGEM, ROAD LA QU51TA Cay 92253 P. IX11L 18M- ING CA PZ264 � ti .(?sSk -4429 0,131, ' USE OF PERMIT ECT . 3i'N`F , AR fS . SP.AE. ENSP,`.?A. rIt`: N OP TEMP ESQ 'i:.83P`i'�'�.f�a'N i��?R, L,` m7nminw con or cons-nivanaN, OM SMA 1, NI SPI+.0 J'If' N 101-000-4Z3;000 d2NIDO Y , f r $ 00.00 ID EM W-3 EVRE-PA r FEB 2 8,200Z r, WY CIF LAQUBR TA RECEIPT DATE � BY / DATE FINALED INSPECTOR y INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Underground Ducts Forms 8 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 8 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 Plbg. Test Final I 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: