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9809-252 (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 Exp. Date 6740:74 /ate//v, ` Signature of Contractor Vol OWNER -BUILDER 'DECL RATION f I hereby affirm under penalty of perjury that I am exempt from the Contractor's License Law for the following reason: ( ) 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, Business & Professionals Code). ( ). I-, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business & Professionals Code). O 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: Carrier ' ' Policy No. STIM7,171 1Q1 N11D 04 6-�-TSUN_f 1,000 7338 (This section need not be completed if the permit valuation is for $100.00 or less). ( ) 1 -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.l-should become su�e`ct to the workers' compensatio'ri provisions of Section 3700Sof the Labor Code I shall forthwith comply with those provisions_ gate i::wA %� r« ' .Applicant � ,� �' :. ,•v..,.:_....�' 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 enier upon the above-mentioned property for inspection purposes. ,Signature (Owner/Agent)., f Date �+?�'�°�+ BUILDING PERMIT : PERM'9909-25z °°"TRDL# pi DATE l VALUATION S24%JJ7„S0 LOT 53 - TRACT 28,3 J r. 30 j B SITEY " APNr�Il��L ADDRESS 'OWNER CONTRACTOR / DESIGNERENGINEEER�� ����77 rr yy T.D. _DES34 8,3' VS',.�r 1 % �JA . � �': i'++�[' r�/ yy �71'A11K.W COINSI s�U(, i 1 N1 . P.O. BOX 17,16 79-293 RANC140 LA QUIN A DR., LA. Qi;1'1nl 1 A. CA 92253 LA. QLAN T A CA. 92233 (760,)771-194.1 C611# 2996 USE OF PERMIT SENOL€: F1,IliMILY ltVLLINQ i 9F D. PLAN :i h, LOT, 53, f'Iw1 MET ,1.5CtES 1407 1NCLUf)I::6LOCK WALE, ©1d P(Y_ 1..Pi..r1 4 CKCK FE,G Ri:DUC10- 75°/i;1*tJa MULTIPLE I8,S'Ur1WE OF Sf PLAN `t'i'.RB. CLT;tr3ilf CJ.idSTIa1SG":CIOv` Z,92`t.0(D SIS' PCIRCH/PPLT:10 2".00 Sr f,;tARA08C RPOR:i' 4700 SF GMAT D COST OF CMftS'`1RUC' ION .241017.10 PERINUT .e+'EE 'SUMMARY CONS'. IVIC'1',IONJrEE 101-000-40400 si.'r1ri ii Ft.MNCHE-cKr,E.B 1,01-OW439-31$ .� $232:24 &0kWJg1CAL1ul; >�L�.C1t1s�At,.1 lil.l�f)t?��g4��tl0ti �1fi9.t . 1'WA4t31N* ,H3IE16:1 401 -419 -WO s 115.75 . . 81 12e �N(:41ui'Q'rON Y9.'E-'#r,���� 101 -Wo. -241-M. - ORADINro !'ME. 101-0U1t413-1:)00 .D20A t;n RASTRt1CIUAR FES 225-000-44,3-342 tl;df 1N PUBUIC P1. ACES. d lONW, ;rL 1-006,255,** $350. Stdiit',S—MAtd COrdSMUCTION AND PLAN CHOCK $7,56734 LASS. PRfs-PAID FEES $0.00 TOTAL PERATIrfFEEN DUE NOW RECEIPT _y DATE �•)) By ! - { DATE FIN ALED INSPECTOR INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS ' Set Backs — /3—Cf L` Underground Ducts Forms & Footings h tl Ducts Slab Grade/ cj_ C.�OI �(� Return Air Steel Combustion Air Roof DeckExhaust O.K to Wrap _3_/ —� Gl� Fans F.A.U. — ESvc Compressor _ Framing 3��� /oZL!- Insulation=�p'cl Fireplace P.L. ��j� Vents_ Grills Fireplace T.O. Fans & Controls Party Wall Insulation Condensate Lines Party Wali Firewall Exterior Lath Drywall - Int. Lath / Final Final 2 6 5FCF_ .Z! 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 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 Sewer Connection �/ 2 - 3 0 - 9 �Jt!�C- Pool Cover Encapsulation Gas Piping Gas Test Appliances Final 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 t t `/J Final �•Z�g-Gl !2_G`� Utility Notice (Perm)