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0304-061 (BLCK)LICENSED CONTRACTOR DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and 04 W Professionals Code, and my License is in full force and effect. O :)ch License # Lic. Class ,Exp. Date CY 1B 10 r` r . 714 V03 LU Z Date i Signature of Contractor `^ m0? r` HCID OWNER -BUILDER DECLARATION W d I hereby affirm under penalty,of perjury that I am exempt from the Contractor's W License Law for the following. reason: Z ( ) 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. 1044, Business & Professionals Code). c") O 'I am exempt under Section B&RC. for this reason LO nl Date Signature of Owner O rn. U Q 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 woricfor 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: Carrier r VYA i':''IdhrD Policy No.7'33%S 'Nt�i►.{ j (This section need not be completed if the permit valuation is for $100.00 or -less). O I certify that in the performance of'themork.for which this permit:is issued, I shall not employ any person in any manner so as tp beceRie subject to the workers' compensation laws of California, and agree that if. I should become subject to the workers' compensation provis'ons of Section /00.of•the La r Code, I shah forthwith comply with those provoons. Date: `� ' 0' '' ''' -Applicant ` ' Warning: Failure to, secure Workers' Compensation coverage is unlawful and shall subject an employer to criminal. penalties and civil,fines.up ta$100,000, in P, 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 appl'icaton 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 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 purposely. I;� k.� Signature (Owner/Agent)'•_ • �� Date �" `. PERMIT # BUILDING PERMIT DATE 431 710:1 VALUATION 9il s rim% oo LOT TRACT JOB SITE M1 t APN ADDRESS OWNER CONTRACTOR / DESIGNER / EN (NEER TO 1'!1 :lkU.J' DEVIL, ;;; P::E.N T SPAJR : i..1 M.Y' 2714 R1 is t Pi`K)V 1.e,•1 � Ti ,�fi�YS 1 .ri, :l- d.3:, U. l�i 1NIT�n CA 91.2S.3 USE 6 FT. VV..Ah1, BOOM f,W 'sty: i 1 'dSi:l t w10 -15r7.' Gly COTTIV;CRPCHO �"OiIJTAllf•i'IOlFe• 1t11,-.a;fCt1•l;i.�tttJ1F,4t� iPd".S'i1C F: $162_U© e 7.;� AIl:?'Si'.Q� APR 0 7' 2003 INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION* DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Underground Ducts Fomes & 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 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 Wring Low Voltage Wiring Fixtures Main Service Sub Panels Exterior Receptacles G.F.I. Smoke Detectors Temp. Use of Power Final Utility Notice (Perm) COMMENTS: