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0304-296 (PAT)l LICENSED CONTRACTOR DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter. 9Ccommencing with Section 7000) of Division 3 of the Business and Professionals Code, and my License is in full force and.effect, _License #' t�Licqq,�Class!'"— Exp. Date 04 2 94 �. d "y Date � Signature of Contractor` , OWNER -BUILDER DEo�LARATION 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). 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 ATgPolicy No. - - (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 CalifcY ia;-,a�Qd agree tha.if"f s%uld become subject to the workers' compensation provisions.of Section 3700 !of the Labor. Code, lehall forthwith comply with those provisions. 1/Date: "112-1162 Applicant( %` C.In Warning: Failure to secure Workers' Coriipensation coverage is unlawful and shall subject an employer to crimin-grreenalties 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-, is 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. 1 agree to comply with af1'City, and' State laws relating to the building construction,` and hereby/authorize representatives of this City to enter upon the above-mentioned property for i , specpion purposes. Signature (Owner/Age tn) - Date`"f�2'�"t WILDING PERMIT PERMIT# -.. 03014, _iQ1TRACT DATE, VALUATION ,' LOT JOB SITE y _ ADDRESS 4 4-549 VIA Id�TM�'n���� APN _f OWNER CONTRACTOR/DESIGNER/ENGINEER RICHARD BLRDSALl.. :. .PLumC�.�.. comoI,'2umom . 48-54PVIA Md,'AtJTC�' 4691 MU'r�S'7`WS.I.L'�t�A).: C:A. D2253 'f'i'•3OTJSAN1.10 PA1:MB CIA, 92276 USE OF PERMIT PATIO t' ,143 SP ,o- 1111i+111WOOD ir,63TT11C;fr. GUVL+I'. " - Pc)RCIDPATIO 8F wYVlvA.[3'.RJrJ) C.08' .ob, CONNTstUii1a.7,00 ':PLAN CHECK WE • i UNSTRUCTIaN AR 1.01.'_000-. 18_000. $51:00 - - XT.RONG MOTION 1TF,-1t 1n ,i01-000 Ai -E, 00 . , '2 4 -APR .•(2003 .: CITY DVLA QUINTA , -.FINANCE'DEPT .'`.'SU-7:OTAT,, 00MMRU T.tONAM1?t PEAN CHECK. 1Z SU I)RE 4?AJD RECEIPTDATE ,/ BY -R 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 Wail 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 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 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: - s , 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 26048,Z B C.33 1?J3I10 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. ( ) 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 STI Xf K, N'fAU> Policy No. .229-,S4Y�-201A (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: 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 property for inspection purposes: Signature (Owner/Agent) Date r PERMIT # PERMIT -' t --BUILDING DATE I,- VALUATION , 4;4sr 94.t5t� LOT TRACT JOB ADDRESS 4,%-, 8� VIA I�'NC°,�h1r� '17 ASPN OWNER CONTRACTOR / DESIGNER / EN INEER k"I(.%A%P?iMiAL�T�,l1 :r_T.COJyY: 48 -Jqq' drdnryyd• •. 71'0tTMTa-L�dTSCc,"�..f':{`;��Ss die, :LA QujmjC4 92:253 ri- OUSA141) P Al,2KS : CA 02276 3106 USE OF PERMIT I01 CIl APl1Fi18T D.J" A..11 t ZF, tL V QA. 1610 ST ' .'C•.l7 dlt7.ld3 Y. ait�'r'SFnS.� :,.�A! �.�4.�.Y�a�i ' Rl 10h 1 Ti�#�M:i FEE* ti'MO.1aWO 10 . FLAN a H �.'1ti. FE'L' 101 <(){1*.,1y 9_3 I N, 0410 commM 1':f=1110Bi MIS i 01. 100-A I P1.1000 S'TRONO MO`k 1e"a11 MIR - ME) 11131F.LkV YS.%�.K,.f.rI sDIM, 1v0c+vr RECEIPT DATE BY DATE FIN L D INSPECTO INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVAJAr MECHANICAL APPROVALS Set Backs Underground Ducts Forms & Footings Ducts Slab 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 y — 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 Pool Cover Sewer Connection 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 Final Utility Notice (Perm)