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9710-075 (MISC)LICENSED CONTRACTOR DECLARATION I hereby affirm under penalty of perjury that,l 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 591%i B 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: Carriert 1 /� Policy No. f U'N JNS 4179 (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'coouro Worl(cro' Campcn3atior. coveiaye 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 Directo.r.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. (.: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 BUILDING PERMIT PERMI4# -075 CONTROL# DATE 110/1")7VALUATION S o LOT TRACT $097 o97 JOB SITE APN ADDRESS 47.,.9)9,5' U MCiN' IGO OWNER CONTRACTOR / DESIGNER / ENGINEER 1570 MOl:fKi-1O'LLCM DRIVE, S1X"@TE 266 157013.[tt)OKt' O L()W. DRI,VE, Sf.Jf'I'.E 208 SSA.( TA ,fetvA i s 92705 6A:Kt"�A &NA. CA. 9270,5 USE OF PERMIT Mi.wf. ` ;;1t yyn� �+�te�T y� E, t ,&�C f� S+1�yC..1.f.i.Y9; lA ED �bl1 I9? �t"��it`,t"4:��i��."t7'�(�'F�t�Jt`"�`�t:.>h1 ANS:►PI A'I+}J�i`S�i>~njt''yy��'.. �y�+{" I �//���o�U!) DATE By DATE FINALED 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 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 I 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 Law Voltage Wiring Fixtures Main Service Sub Panels Exterior Receptacles G. F.I. Smoke Detectors Temp. Use of Power Final Utility Notice (Perm) 619.-863-8917 ASSESSOR 619-8638917 712 P01 OCT 09 197 10:17 COUNTY OF RIVERSIDE OFFICE OF THE ASSESSOR INDIO DISTRICT OFFICE 46209 0as14 &., Rm. 406 t' lnd/o, Co 92201-5994 Far p ,(619) 863-8917. 4'UICK FAX F O R I M M'E D I A T E 'D E L I V E R Y ;. 'TO: La QuLda Motto kssessof FROM: DEPT ' 10 /4 /9 =7 DATE .OF TRANSMITTAL: TOTAL NUMBER OF PAGES,. INCLUDING COVER, SHEET: A D D I'T I 0 N A L I N F O R M A T I O N °. 7 7 s s`noi memd h wil-h fpcords. lQ+ as krw Am - rgtey.�Kals Attv rc f r- 3 -2!u 2,71-= q7535 1/ta 6W3 120 dad - U "onyl.aja s 3 12&Q21 ia A40nj;fi o f 619-863-8917 ASSESSOR 619-8638917 " 712 P02 OCT 09 '97 10:17 ;. IZ 96 cc rN �• 1 \ y � C n-� U Qo a Oe a O b.J L ®q ejy • \ � A � �4 Nod '�°� -^ .: re!' .'._.... �ypJvarE SrMCrYI ra. tJr" i, v+ \,• ©: + e 'It Pg\ co.o 'fes � � �� .& � ^ a w `Je Ya �0 .0 I �. % • Iv� r, W �. t• 1' 4 W obi 9 �y l� �� N vA i , 1•Yr." IP 1rq '. be fit VIA - to t as a`' � zf .. .a -� �~• MSO —' x. 1.19 Ij -Opt IL v lr y ♦ b. l .4r� v�Vw' � �S70Eff) O;rOaf t' JptC 1y.o9 11.M - t%l pi.6t,y'`5 10 a p� i. b O� fV w Ol N • �V" .. ♦ `fit. pJl.f1 fa.+. 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