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9607-107 (RPL)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 //I License # Lic., Clas/,?W / Exp. Date ly vDate �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 pert rmance of the work for which this permit is issued. ( I have and will maintain workers' compensation insurance, as required by Section 37.00 the Labor Code, for the performance of �he.vyork ffor which this ... s, k e llvv r ?iH+fi s permit is issue My workers' compensation insurance, carrier & policy no. are: Carrier Policy No. (This section need not be completed if the permit,Galuation 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._�` \pate: .• `' ' _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 ofdsuch permit, or cessation of work for 180 days will subject permit to cancellation. � J , I certify that I have read this application and state that`the above information is correct. I agree to comply with alljbtq, and State laws relating to the building construction, and hereby authorize'representtativesrof this City to enter upon the above-mentioned property �for%inspe/ction, purposes. Signature (Owner/Agent) ' f �'/�/t/ /1•�� Date BUILDING PlERMIT PERMIT# CONTROL# i)�t) i 9.117 3781 7 � 9 1 DATE 71 VALUATION S.4�r�)t�11.1Ri LOT TRACT ADDRESS-F��:�9f1`7APN OWNER CONTRACTOR/ DESIGNER/ ENGINEER ' TO DE,SP 11, 11F V Ir. ,f);;'i:' VfIr9 POt: LS S ; SPAS F i..l. };t.l.`!i. 17 10'411 A0 I3OAItlu WA JNk FA2 1,A f'jANTA -CA !)22s3. PALM DIRS1? CC Cts 92260 ffil' 1771.2 1�#t ftiia)'t1=1t?-9i�i}f) t:IAL4° 355 USE OF PERMIT 11100L A;NV) NPA ONLY +ilr4'1'.rl�r0' fD'�35''IDIVgT�d1:d��i :14,Q➢{ifi.61�41 PEJUMIT 1Ffi• E SUMMARY P14AN 0.0—X ; f.f111-000-434»3I8 CONI RIUCT1ONfice 101.000418-000 51530 'NO-ZRANICAL 14' _., P001. 101-tm-121-000 SUM � r. VSrNRICAr,hV,-M: c 1. 101-400-42.0-000 545,00 •r'I,t,fVIR(NO FIFE OU 101-00074VID00 527,00 � © M C, uti LESS MME-PrAIOIT S $0.00 RECEIPT DATE. BY DATE FINALED INSPECTOR INSPECTION RECORD OPERATION I 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 Wall 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 PI . 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: