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0304-132 (SFD)LICENSED CONTRACTOR DECLARATION U) •.: ` I hereby affirm under penalty of perjury that I am licensed under provisions of F- . " Chapter 9 (commencing with Section 7000) of Division 3 of the Business and (V W Professionals Code, and my License is in full force and effect. O M License # Lic. Class Exp. Date LO Z r- Date Signature of Contractor O OO I. -_J 0 OWNER -BUILDER DECLARATION HWW I hereby affirm under penalty of perjury that I am exempt from the Contractor's U) License Law for the following reason: Z_ ( ) 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). ce)() I am exempt under Section B&P.C. for this reason N Date Signature of Owner ON O d< WORKER'S COMPENSATION DECLARATION o Cc I hereby affirm under penalty of perjury one of the following declarations: Lo H p () 1 have and will maintain a certificate of consent to self -insure for workers' X W Y= compensation, as provided for by Section 3700 of the Labor Code, for the O � Q performance of the work for which this permit is issued. Co Q () ( ) I have and will maintain workers' compensation insurance, as required by O U Q Section 3700 of the Labor Code, for the performance of the work for which this LO H permit is issued. My workers' compensation insurance carrier & policy no. are: oo Carrier u'!`%�":,'? I'tiJtD f Policy No. iu�}G'Aea2-01 ;t d J (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 personih any manner so as to become subject to the a workers' compensation laws of California, and agree that if I should become 3 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 BUILDING PERMIT PERMIT# DATE VALUATION LOT '= TRACT :�; , . r c x p �f ,� Vie, ' 29WS JOB SITE APN ADDRESS 3({ -fi4f6 111A SA 0� F.:>i '71460- �5.� :�I OWNER CONTRACTOR/DESIGNER/EN (NEER i1�i.;4.;".i:'.j.':'�.iK -fs:1.1.0�,:1''f.•r(�rto,/:1('.htiry�°7 r y p7J 50.H4:R.!.! 7. .r ..L \.LIV.��' �..� �?il ,:!' ZY�fI ��'�. �,;/ ,gr_(3 / W,.RJ `",�:.f ti1'...il T !.,'�. Yi ���yt IrCil_^ '('. t." �N T. - s'y P. 1f•'iA i ) •.Y .A '.'F.!_.` --.fry. '.. h1\!' 1 �'7 f°�L1� f 5 e '•Y�' in'� if.°1, ( 'Td,.l.. A 1 1 .Y % USE OF PERMIT 31NI'l A;' FAME ? Fr . 1,01 96, f.:.rN 1R,. Pi:TMr1T 210i uh.C1'1' .u4.c .t.. ox- C.11.,IwYC _WAd,LA P001, `3TA OR f)R;.!Vt»WI�Y APPROA- J'6, 7r,%, Fad..AN CHECK FEE DUE TO MULTIPLE, OF UL N0, V L.A1.1 T y FfL; C:U11TOM f.".C�3! °I .f=:.0 .•'•T'ir>F! :,#> �'.ift� ?i F' F;.)ntui-IlPtl ICr 'ili�i.�fit S.N. "STfA#.:A'.3:. 71) 005'17 QF C_;)T4'i1TkTT0_:1 J0J r2:,4,1X`4_30 P MAS(i`.ii`It F` .SU,Ne1:fiPFfVWY (YN 7' t:.. dut.�%nLA'�eTt:,'.�.t, k'fi3:�; 1�1 �UfJrUv�1:�', ••ti•:)rf �1 �?�±.Bttl L41WCr 'FTRICA. L, 31`FZ ; f1 i - ins; -4 2 Cf -000 I LLI jV(BINt:I Y&N, 1. L11. -t 00.4 J 90 ate.) $1 17, � S 311R.f.' HU A.!i0111014 .3 EE 10!-0WIr; .,Z4 i -000 OR.f+.D1. 40 FEE I Ci I -000-A4"3,.000 J�f�i'P,•;i,f�F'�Fi. IFc4!?.F1.t:"!' t�N', $7,tl,;lg,ttp; 4T FJUBLdr.' P1, ACi&3 - If3!-SK 2'1'()-f`„fjJ-445-00 A14D PL -At C.1 -T 121 9 i,21 1.2'i $I.D,Cit i �'(.'.t`,f"v o';?:3+t:tV9.;4':e..I+'��i�`1+,?){.1�'+', �`�<:)irL'' �•�,'a.;9.'?,i';-' RECEIPT DATE BY DATE FINALED INSPECTOR `RP OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUIL®INO APPROVALS MECHANICAL APPROVALS Set Backsp Underground Ducts Forms & Footings Ducts Slab Grade Return Air RnE Steel Combustion Air Roof Deck Exhaust Fans O.K. to Wrap F.A.U. .0 1/ rill I V I Framing — , 3 Compressor Insulation • Fireplace P.L. ents Grills Fireplace T.O. Fans & Controls Party Wall Insulation Condensate Lines 01. Party Wall Firewall Exterior Lath Drywall - Int. Lath ell /T Final Final P®®LS - SPAS BLOCKWALL APPROVALS Steel Set Backs Electric Bond Footings Main Drain Bond Beam Approval to Cover Equipment Location Underground Electric Underground Plbg. Test I Final Gas Piping PLUMBING A OV LS ! , 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: r" 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) t 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 §."3!570 Ia MCI ate ` '13 ' 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. t4) 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 `3T AIT taUWD Policy No. jbz;Lf£2 'i. (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. ' �te: �.. �,� 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. T.r 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) 1,='"�-�'�-=•—-�• ' "- Date F r� PERMIT#. BUILDING PERMIT DATE VALUATIONj,j e�; ; yy�„ LOT 96 TRACT 4 JOB SITEd-Q� 5 �'� 'i: i ADDRESS APN J�+' •atP't:� OWNERR. CONTRACTOR DESIGNER EN NEER JLlVq1�tS,AC 0,*RPJRAT1ON 77 wJL4 COY?YCT3EV�.VE i7 13 77-645 C01'+Sb3MMI)Y-R, 2,T.7171,1 1.5+�.i _ Pj? M r)"Le;1. 92211 P `AIN.. D E-Ive CA 922:60 i' TiU 3Y �£it:34 IMIA i 1 USE OF PERMIT WILY LA9o-,951, Y',L.k7;2yL.,•�{�A,73.0,71sib!177,5 1111.51, SAS[.• ��c�(sA..�.a{�Dn&Aa7+<--7.t��p ,i�b':��{I:, `'f i+•t�3 la{vf.C�.1M.17r M.'3'4 ii„J1�4fw'S CoN C UP, 119..:.711 CT'11a K. h' . i,-iUP,I "i'0 ''VltJI.J.is �1> Lt ItSslJJ'cl�r11 E OF' &AM Er a;'i.,A;k-I 1, ypf, ' f;IJ;'rr<•;��! «.,0���:a^�5,,..F'sy?i�i 7�f�7,i7v �!� � - t3d"€'?IF•Y.i;.'l".'aG5y0.C�XI - ,.C� tSF 4SfAA5,��'k,`+1?=�: E0;1'1,7y'f.�Y� �' �i��1.V°• N"fi+ . 7 �� � ry, y�. �•.� �± y�• t, •�- f p�* q 7 gay. C°�►�I�3�'P->.iD�':iDG3'?�;a•;�:r 14?'1..i?�?H`i's?>�--©C�� l,t�f#3E1 PLANC,kLYP',KF;'%-, M't?C HA'SICAL:YK t t7t.-000,4 tt adCt f 9,LF,CY°RIQkL FX10•, i;J; tli t; PLUMMIX10 TIRE -000-419-00") I raI-cloo-:?:!d l -o0o. 'A. 4) AD011' :FE X10111 1 JXiPY1R. ART V4 PU1413C11ZLACE,,'J K'SN'i"'M "'T"11-000-4.46-006 %6013a : tj,T:I)'�:� C0.14' AND 3''IX-1 traC-MIL, I ,c'a :••F'�', CD Dtu $0.00 o D ronmx r� Ir: .11111 D E1.1NOW v42 5.1.2•? MAY 2 7 2003. CITY OF LA QUINTA FINANCE DEPT. RECEIPT DATE- &i i.i � BN � L/. ! 7 D FINA I EC '1 ,,% .J i 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 • $• O zS F.A.U. Framing Compressor Insulation Vents Fireplact-P.L. Grills Fireplace T.O. Fans & Controls Party. Wall Insulation Condensate Lines Party Wall Firewall Exterior Lath dUlel 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 m.Llnderground Conduit Rough Wiring Low Voltage Wiring Fixtures Main Service .Sub•Panels Exterior Receptacles G.F.l. Smoke Detectors Temp. Use of Power Final Utility Notice (Perm) COMMENTS: