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0211-048 (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 # Lia Class Exp. Date 93 B 4430fO3 to 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 Se ion 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 ,X t� 3>3IJ 1tr'1IPolicy No. W.i%,7.QD0Q4W340!2TE (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 s : all orthwith comply wi hose pr isi ns. Date:/�I �' �" Applicant ' �� ' Warning:;Failure to secure Workers' 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 forin 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'fo�180 days will subject permit to cancellation. I certify that I have readitfiis 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-hereey authorize representatives of this City to enter pon the above-mentioned property for inspection purposes. ,-Signature (Owner/Agent)-1 L",- Date,% BUILDING PERMIT PERMIT# DATE VALUATION LOT _ TRACT JOB SITE ADDRESSlt�e.Of3', APN D 1l OWNER CONTRACTOR / DESIGNER / ENGINEER 73.121 M7;. WA_H. 34.3fa 00 73-121 SLED 10P;F.N1114101 0 PAU�k DIMERT CA 92260 PAI 1ADMER.27 CA 921,260 USE OF PERMIT SWQUf.r-AiAlLY 'DW X400 SIFID =• LOT 3NOL„INAo-A PERMIT DOES' 0T-fNCLU,0,fs 1ILOt: r ' WAWA P004 SPA Oso MUCG T.O'N `I'&KAX CH.F5.,CK PFP,' DQ9 TO MUL T..TPLA IS3UA:NCIE, 6VT;t MH, P1AV 'ri 1M*). CUSTOM ONLOI'i.CiUMdRYN 3110.09 IV t�t�dRCI=il�.E TIG 3'.Siixo Sir y ESTIM, E~1D C''C;Igr CXV C1011TITTR SC' (M 27.5,019.5D 00340Tr UMON P-? 101 -000-4 1 PLAN CH&X MME 101-0001-419-:31 301-00-421,000 Xt. `f`R,IC,r I., f: L9 101-0 00-14-20 000 �1eta.F+RT Pl.tI'At N14C# VEK 101-000-419-000 STRUNG MOTION .FE Z . T2.&SITJ 101-000-241.000 $.4e7, Sc, Gij?Ai iINC} i RI?, � �! X00>� �;3•(�U�1 � i °�,�p D.TE'MOMM It,4P. C -T ,.I'; ART IN PUBLIC PTAC°;E5 - k.$ tis: 270-000.445-000 87 -MA �.. "O #'t"Rxi'��'�.`Xt�l�'.A'k�I91s1 J�1 r"`f t CT; 9,'4,M:1.43 1=95 PRE -PAID RRE tf, NOV 1 1 02 r°1 ail MIALF KW+Yf:��:�:ENDM O S4,647,43 ,. v CITY OF LA QUINIA FINANCE DEPT. RECEIPTDATE t BY DA IN ECTOR j A jl 1 e� k (•1 INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Underground Ducts Forms & Footings jq Ducts Slab Grade Return Air Steel Combustion Air Roof Deck Z kw_tsExhaust Fans 0. K. to Wrap 3 -all's 96 F.A.U. Framing S Compressor Insulation • o _ Vents Fireplace P.L. Grills Fireplace T.O. Fans & Controls 00-00 Party Wall Insulation Condensate Lines Party Wall Firewall Exterior Lath Drywall - Int. Lath v Final BLOCKWALL APPROVALS Final 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 r Sewer Lateral Pool Cover Sewer Connection A -Z -,-dP .ze Encapsulation Gas Piping Gas Test _ejn�- Applianges _ Final Final Utility Notice (Gas) ELECTRICAL A PROVALS Temp. Power Pole Underground Conduit Rough Wiring / Low Voltage Wiring / Fixtures Main Service / Sub Panels f Exterior Receptacles j G.F.I. _ Smoke Detectors T Temp. Use of Power Final Utility Notice (Perm) COMMENTS: