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0308-251 (SFD)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 I.Exp. Date 728102 13 IRC � 1 / , 9/30;04 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: ( ) 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 her 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 iso ed. Se(,) I have and will maintairrworkers' compensation insurance, as required by ction 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: CarrierO�. D I�3?',E'L1.i11�1(�,' fi4J8i? Policy No. Ar1�C'�t1ft��f5�1C►€� (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 tF ose provisions! Date: - ��% '�gr '�' °� Applicant.',�ta�f%lt� 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. 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 isnot 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 representatives of this City to enter upon the above-mentioned property for inspection purposes. Signature (Owner/Agent) QAC/ �t�lf we%`- Date 4� BUILDING PERMIT PERMIT# DATE VALUATION LOT�`�^� TRACT '632.60 JOB SITE AP N ADDRESS 78-4m VM :PAVTON OWNER CONTRACTOR/DESIGNER/EN INEER UNW AR If ONM ©#' CA,1T OR -411A L1f'.�1.�.tr R ROWS CYF C.p+LWORNM 78-401 Cr H..IOHWAY 111 78*401 C i1•SCrHWAY 1 l 1. {:AQUINTA CA 92253 1..&gnNTfs,, ON 92253 t r wp-77.0131 iw1s:' # 3434 USE OF PERMIT SizC) • 1..0'1'.3; iail�.:'ri �Y')8'K. i1�Tr€i,tUf1'P .l50ES° e+1�3'f' 1:1+1C.C:U2�i,SLOGi;v . IVAt.f.,S; P' 450,, SPA OR DRIVi IVAY,APPMOACH T�.'ACT CONST121Jtr+710N 2,804.00 ,OF PE7R WRA)''d'a0 2.36,00 S CAR.ACIEKARPORT: 4200 3F r ,[ 's'1Te'1.,M C oll r oir ce)NIRRUCT1.0,11 CCNB'lRUC.TION T K 101wOrJ0-418"000 $5S"3d,®6 PLAN CHECK Et+:,: loll-000-4139-:5tCf S"Y2236 MECHANICAL FEE :01-000421.000 $60.49 10) -000-420-000 $143.31 I'1.'U"mATH a rin 101.000.419-000 $167.25 STRONG MOTION FES - RESID 101-000-241-000 $16.26 CUOMO FET, 101-000-423-000 115.00 Dr"LOPtER IMPACT PPP, $7,405.00 QwIT 3- TOTAL C. OWSMUCIUDH AM IIAA3 Ck1M&K X4,410.98 -- - Ix,°;14 I*H-PAta3 F+ M x2 $0,00 -- RECEIPT ` 65r.E DEPT. f� B. ATE,F I SPECT r ����� INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Underground Ducts Forms & Footings Ducts c� a Slab Grade Return Air —r_J - _ Steel Combustion Air _ _ Roof Deck rq Exhaust Fans O.K. to Wrap F.A.U. - _ Framing / Compressor P fill _ Insulation Vents _ Fireplace P.L. Grills Fireplace T.O. Fans & Controls 1_ 71 Party Wall Insulation Condensate Lines Party Wall Firewall _ Exterior Lath Drywall - Int. Lath Final Final _ POOLS -SPAS BLOCKWALL APPROVAL " Steel Set Backs Electric Bond Footings Main Drain Bond Beam Approval to Cover Equipment Location Underground Electric Underground Plbg. Test Final Gas Piping PLUMBING PP V LS 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 COMMENTS: Final I Utility Notice (Gas) ELECTRICAL APPRO ALS Temp. Power Pole Underground Conduit Rough Wiring (� Low Voltage Wiring - Fbdures Main Service Sub Panels Exterior Receptacles G.F.I. Smoke Detectors Temp. Use of Power Final Utility Notice (Perm) /�