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0002-028 (SFD)LICENSED CONTRACTOR DECLARATION I hereby affirm under penalty of perjury.that I am licensed under provisions of Chapier 9 (commencing with Sktion 7000) of Division 3 of the Business and Profe;t-;Z-r�ls Co , de,-anclmy License is i . n full force and . effect., i se(# Lic: Class L cen Exp. Date rfP U 14, 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 t - he property, or my employees with wages as their sole compensation, will do the work, and the structure is'n9t. intended or offered for sale (Sec: 7044, Business & Professionals Code). 11 as owner of the -property, -am exclusively• contracting with licensed contractors to construct the project (Sec. :7044, Business &. Professionals Code). - 1 am. exempt under Section B&P.C. for this reason Date '—Signature Of'Own& 'WORKER'S COMPENSATION DECLARATION I hereby affirm 6nder.'pe . neilty-6f perjury '6ne--of--the following declarations: I'lhave and wiil,maintain a 66rtificatb of consent to self -insure for workers' compensation,, as -provided for by Section 3700 of 4he Labor Code, for th6 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-iss6ed�,My,workers' compensation insurance carrier & policy no.'are: Cagier .-Policy No. c'T 6733' (This section need not be completed if the permit Val Liation. is for -$100.00 or less). I certify that in the performance of the work for which this permit is issued, I shallperson employ any in any manneT -soas to become subject to the workers'. compensation laws of California, and agree that if I should become subject to the workers' como6niation provisions of Section 3700 of the- bor Code, I shall—forthwith comply with those pr6visi6hs. Date: yl'/ /100-ApplicanL Warning: Failure to.secure Workers' Compensation coverage is unla L I and shall subject an employer to criminal penalties and civil fines up to $1100,000, in '' addition to the cost of compeHsation, damages as pro 1 f0r in Section 3706 o I of the Labr Code, interest terest I and. attorney' s fees. IMPORTANT Applicati&n is hereby made to the -Director of Building I 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 and4or.whose. benefit work is performed under or purivant 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 asa'result of,this application becomes null and void if work -is not commenced within 186 days from date o'f'issuance of such permit, orcessation. 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 offhis City to enter upon the above-mentioned. prbperty for inspection purp'oses. Signature (Owner/Agent) Y PERMIT # BUILDING PERMIT VALUATION LOT TRACT DATE 48 29_W) JOB SITEAPN ADDRESS 49.5-57VIST APPALOMINO OWNER CONTRACTOR DESIGNER ENGINEER r"D T DEV 01 L0. N, XAk,"J;, %,., A�4,� L'i CD "t 0110 Pnxvz6tv�uc"n-m PO BOX 1716 79 .1-10, Uk QUINTA DR, U -29.5 RANC LA QUI NTA C �A 92253 LA QUII-ITA CA. 921W�- (760)771-1941 cm,L6 USE OF PERMIT SING11' PAM Y D* BLUNG &'.M.LOT -18 AMAN Mift'� P�MCM.IT DOES WOT Nfa.UDU BLOi�k NWUL OR I FEE REDMTKYN 1�-'OR MUVrIPLE ISSUAINM OF PL IMj<" �A SK&A-E PL i�N TN"PS" PolkCHIPKM SP" 0A1WJ1YCARPGR!1' 693.D03F CONT OF "E'UNSTRUMM"') P E; R tW r! i F E E 8 VWM, A'K-V CON ST RI)MONFE-NI .101-000-418-000 31,203.(X) V. L A N'(73 +_: K 'SES 0! -(*()-4:3'x'-31.9 $ 47,07 .&MCIIAMCAL FIX ELECT WCAL FEE. 101.00-41MOO 5TRONO W)"110.IV F"813 - R!5�Sib 10.1 -00-0-24A -10M $x" D11 V1151.0PER Imp hCT -a S1.907.00 AFT IN,"PUB LIC; KACBS - RIESID 701-M-255-000, $402.29 �InVrorrm, CONISIRIJIG-r-ON AND PLAN CHEX'K rRAIDHES LESS � Pr% - 41 .00. 0. f(.YfA.L-,PE9M1T IFE DUENOW, 17.97 RECEIPT DATE DATE FINALED INSPECTOR # 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 O.K. to Wrap F.A.U. Framing Insulation 61 tom- Compressor Vents Fireplace P.L. Grills Fireplace T.O. _ Fans & Controls Party Wall Insulation Condensate Lines Party Wall Firewall Exterior Lath f4 / - Drywall - Int. Lath Final Finad BLOCKWAIZAL 113111W.11AI A PROVALS POO S - PAS 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 vv C Heater Final Water Piping Plumbing Final Plumbing Top Out Equipment Enclosure Shower Pans O.K for Finish Plaster Sewer Lateral 03 Pool Cover Sewer Connection Encapsulation Gas Piping Gas Test Appliances Final Final Utility Notice (Gas) ELECTRICAL A PROVALS Temp. Power Pole Underground Conduit Rough Wiring Low Voltage Wiring Fixtures Main Service ` Sub Panels Of Exterior Receptacles G.F.I. Smoke Detectors Temp. Use of Power Final Q Utility Notice (Perm) COMMENTS: