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0310-162 (BLCK)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 ?,05o] B 036 C42Ift 11130/2C Date 1r(, Signature of Contractors 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. 7U44, 81,101esS & PIUfeSSIU11alS 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 carrier & policy no. are: Carver STATE I?U?313 Policy No. ISW70 (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 tho,se provisions: Date: �Z N/ Applicant �� Warning: Failure to secure Workers' Compensation coverage is unlawful and shall subject an employer to criminal penalties and civil fines up to $100,000, in addition to the cost of compensation, damages as provided for in Section 3706 of the Labor Code, interestand attorney's fees. IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the conditions and restrictions set forth on his application. 1. Each person upon whose behalf this application is made & each person at whose request and for whose benefit.work is performed under or pursuant to any permit issued -as a result of this applicaton agrees to, & shall, indemnify & hold harmless the City of La Quinta, its officers, agents and employees. 2. Any permit issued as a result of this application becomes null and void if work is not commenced within 180 days from date of issuance of such permit, or cessation of work for 180 days will subject permit to cancellation. I certify tnat I have read this application and state that the above information is correct. I agree to comply with all City, and State laws relating_to the building construction, and hereby authorize representatives of this City to enter upon the above-mentioned property for inspection purposes ./Signature (Owner/Agent) .� � Dater��/ +#�� � ztrih �'"ii•i BUILDING PERMIT PERMIT# 0310-168 DATE / _ V LUATION LOT TRACT JOB SITE ADDRESS &3-M0 ��.W.+Y.U.0A IMLA, APN 774 -0944 -ON OWNER CONTRACTOR / DESIGNER / ENGINEER SM"_413 REL"AP J.AMMS C. DEt,.1[ NAP, JR.. F'.O. BOX 297 73.300 FWDLFN8C.K LA14 ; PAl:U DESERT CA , 9226E XMLM 17n.MZf • (,M 922611 (760)777.9572 CRL4 2905 USE OF PERMIT MD'k?r� EAL .BUMDY>;,1 G 130 LF BLOCK, WALL 6' tIIf3I•i' CITY STANDARD 6 FT, WALL 1.Sia,00 LF :11,°S'.~fikll/U; 9D 4�0Sf OF C:O.Pi THITC1.10H 46 M.eL)ti PERM MW 910MMAXY CONST RUC TIO'i' FEE 101-.000j-418-000 �i"�;. N V OCT 15200 Clay OF LA Wit�'oPs FIMANCE DEPT..,. ;,• .SUB�TOT.6d C01ATS'fitilCTXoil .$,Adm P3�P�AT L'FCF.0 $172.00 LEW T=ick:=FAM D. $0.00 '.PO'L'�,.t,, FILE V.e'f FEES DAN, MOW 172.00 RECEIPT JDA IE /j r BY DyATEFINACED IN 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 OX 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 I 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: