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0312-144 (RPL)'LICENSED CONTRACTOR DECLARATION I hereby affirm under penalty of perjury that I am.licensed under provisions of Chapter 9 (comme?rcing-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 03 I. it - .3 a ,t _ Li1yi l %tom Date !'%' 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 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. (\),J.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 errA'TS C:OR9PY1113A` ! Policy No. 040-6108-2003 (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. Date: 1 - %, 1 - 63' 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. 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 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 prope7).' , inspection purposes. Signature (Owner/Agent) . ✓ %��.,C�K;� Date � �''� -� BUIL DII.P PERMIT PERMIT# DATE ' ' VALUATION LOTS ¢ TRACT 0 w� JOB SITE '� APN ADDRESS 54445 rS,V7NTJ?kffl iWrKRA - OWNER CONTRACTOR / DESIGNER / ENGINEER M AWDIOR Ma Z2. YO UNG l:lt<1..D01CNJ%. POOL,`3 & !KRAS (-1o7? MAN 54.945 AMN-f.CF,A1;•? MUTZRA 86.100 A:ENUE 54 L& QIM, " 4 CA 92253 �.:C3A1::-''HISUA, `.;A 92236 (760)398-9222 C`'B1.,A 003,55 USE OF PERMIT POM, tawl()k SPA PODUSP4 ALARM SfFSARIU4121,' SHALi...BE IN PLACE AT PRF, 0,VPW y i0'4, IsQf f.i'f°UMT 1r RCU)MU F NOT 44CLU D O Pool, AND/OR SPA A090.00 L -S U DSC 2 3 2003 CITY OF LA QEtstd-J;.a 1r4IVTMATIK..0 MINT OF 0014 'Y'.i�t.UC.".KION PLAN CHECK FLE 141'=4 00.439-318 91221.85 CONSTRUC TIZO d FEE 1(11_0004 8-000 $IR9,00 M:1t f;2HMICAL FEE -- POOL, 101-000-4111-000 $24,00 ELECTRICAL FLEE — POOL 1011-000-4-20-000 T,115.00 11L0MDI.1'4(s VSE, -- i 0014, 101-0004,19-000 MOD 81.1B-TafAL C;C W1A-RLYC 1 0:N X19 PLAN O} 1i ;1C +Q�'.5 5 LFZS :fs1:',R.;PIKD ;C `€13 $0.00 TOTAL i'ET%M'1' F0319 DUE IT OW I W7115 RECEIPT I DATES �`1"I�13 Y D7INALED p _ /_ I INSPECTj)$� lI 1 .INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Underground Ducts Forms & Footings Ducts ,,lab 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 POOLS - SPAS BLOCKWALL APPROVALS steel Set Backs Electric Bond Footings Main Drain " Bond Beam Approval to Cover Equipment Location Underground Electric Underground Plbg. Test Final Gas Piping — G2 PLUMBING APPROVALS Gas Test •Electric Final Waste Lines Heater Final Watei Piping . Plumbing Final Plumbing Top Out Equipment Enclosure dower Pans O.K. for Finish Plaster Sewer Lateral Sewer Connection as Piping Pool Cover _ Encapsulation Gas Test Appliances Final •� � d COMMENTS: 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) t� w Building Address L6 Owner Mailing LD Address /Y v��� CityZip STS/o Cf c Contractor 17y? _Not Moy Address 4 4 Qum& P.O. BOX 1504 APPLICATION ONLY 78-105 CALLE ESTADO LA QUINTA, CALIFORNIA 92253 vniA 9Z r6a Tel. /6oy 2�3 S�rM� --( A 6b11 -e City Izip I Tel. State Lic. City & Classif. _ �� a6<`Y Lic. # Arch., Engr., Designer Address Tel. 11LDING: TYPE CONST. �^ OCC. GRP. P. Number 3�f3 Legal Description Project Description Z22 - CityI Zip I State Lic. # LICENSED CONTRACTOR'S D LARATION I he;abya irm t I am licensed u er provisio Chapter 9 (commencing with Section 7000)i ' 3 of the Busine ntl Professi Code, and my licenseis ' full fort neffec—7.,V� SIGNATURE DATE OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason: (Sec. 7031 . 5.8usiness and Professions Code: Any city or county which requires a permit to construct• after• improve, demolish, or repair any structure. prior to its issuance also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, or that. he is exempt therefrom• and the basis lot the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500). 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, Buisness and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon and who does such work himself or through his own employees. provided that such improvements are not Intended or offered for sale. If, however• the building or Improvement Is sold within one year of completion• the owner -builder will have the burden of proving that he did not build or improve for the purpose of sale.) I, as owner of the property, am exclusively contracting with licensed contractors to con- struct the project. fSec. 7044. Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for Such projects with a contractor(s) licensed pursuant to the Contractor's License Law.) I am exempt under Sec. 8. 8 P.C. for this reason Date Owner WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self -insure, or a certificate of Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800. Labor Code.) Policy No. Company >eopy is filed with the city. I] Certified copy is hereby furnished. CERTIFICATE OF EXEMPTION FROM WORK 6 RS' COMPENSATION INSURANCE (This section need not be completed it the permit is for one hundred dollars (S 100) valuation or less.) I certify that in the performance of thg 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. Date Owner NOTICE TO APPLICANT: If, after making this Certificate of Exemption you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code.) Lender's Name Lender's Address This is a building permit when properly filled out, signed and validated, and is subject to expiration if work thereunder is suspended for 180 days. I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives -of this city to enter the above- mentioned property for inspection purposes. Signature of applicant _ Date Mailing Address City, State, Zip Sq. Ft. No. Stories No. d Units Add ❑ Alter ❑ Repair ❑ Demolition ❑ n PERMIT Plan Chk. Dep. Plan Chk. Bal. Const. Mech. Electrical Plumbing S.M.I. Grading Driveway Enc. Infrastructure AMOUNT TOTAL REMARKS ZONE: BY: Minimum Setback Distances: Front Setback from Center Line Rear Setback from Rear Prop. Line Side Street Setback from Center Line Side Setback from Property Line FINAL DATE INSPECTOR Issued by: Date Permit Validated by: Validation: