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0307-153 (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 # Lic. Class Exp. Date r 6f30IUt;•' Date t'" / -' Signature of Contractor J - 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 br 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). -� O I am exempt under`Section', B&P.C'for this reason Date L- _Sign`atuof Owner WC KER'S�COMPENSATION DECLARATION I hereby affirm under penalty 'of/perjury one of the following declarations: () I have and will maintaina certificate of consent to self -insure for workers' compensation, a�rovideciAor by Section 3700 'of the Labor Code; for the performance of'tfie'1.work for'i hich'this permit is issued. (-) I have andw ill maintain workers' compensation insurance, as required by Section 3700 ofl.tlie LaboUode, for the performance of the work for which this permit is issued. My`workers' compensation insurance carrier &'policy'no.'are: Carrier F'rM•E.I:UN'D Policy,No. 1604624A (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: a 2,Lf, "Applicant— Warning: 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 O'eompensation, 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. J` Signature (Owner/Agent)--Date J . PERMIT # BUILDING PERMIT ryry%.ryry' 2} DATE VALUATION + �1 q�S ��ay+' LOT' {j . TRACT 29%144, JOB gITE ADDRESS, r VdSTi�� APN 7`T jfh� OWNER CONTRACTOR / DESIGNER / EN (NEER ►"lLI3�)hi�} C➢" �s, i?I�:M1.51R.EIK— COi7IPIORA`#:f DN' CA 912231 r?,,' ,QJ*DRVI,f�7'kT CIA*92260 Lf 1. USE OF PERMIT - a.nu « t.�yryl •y,/,a'�5.. p� r�{b^.��yy 4r' e..�rv{x�t iy't.�+rr/vCrtycd:r aav,�,e.�,c.�a�, crp:v�. ,. .ti:;. �, . L-VLISy y(-ni. 1+�. t�:1d % f:. B7 Y7,*t` tl.C-�CCL•7�aVS7 , � ' +=dr��pf�� a"�iiv�'ii1�G'•Tlf�%�a. �,�:�3,UL� :��`' . t• PORCI'YRAR . % 10 M03 SY . 0Al2.NOWCAR5 ORT 01.7 COur or, iR 4;100401 am:—is Tort L.yy��yyyy� �p+ yy rya�yy•vp���� ry pqy"� �2a4,rTMt°A7%D ,�1IIn'Ci:.�i'.Lfii /.�54d+ a�'.CY.lFl17;,A.1.1.7L• ' Ct? �ta?''2i�tr`:ftop 1 �.2< 1©3 -00 --418-000- F'"N CH,+:CK ME.' 101-0 0.4,39-314 P"uoeua h9'ECKMIC.L 1i"Et, 101.00-4,21,000 E4,K7RICAL FEEYt?I-ft •�k20,i �;;.i?a ' 11V(JMBYN0 FEE, $168-$o . t'i3OM MOT•.i'C K V01 I P114SI 3 101 _01A1_2411-000 $;;T 39 I�)�i�N:it�PF.,F2 s�,r� w•1' i�L�-': ��.�tcs.ufJ ' ART PUBLIC' PJAC:E8 "rV ME—PAW F. 30. 'M'1',2` L 'PPM-.MITFE 10 Ji.C:72L 'IyCa RECEIPT DATE BY^^��;. �, : •. DATE FIND D SPEC O :m . INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Underground Ducts Forms & Footings A Ducts Slab Grade j ZI af 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 ; •:' i Final Gas.Piping PLUMBING APPROVAL 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_01 A- Utility Notice (Gas) ELECTRICAL APPROVALS Temp. Power Pole Underground Conduit Rough Wiring Low Voltage Wiring / Fixtures 7 - Main Service gel Sub Panels Exterior Receptacles G.F.I. Smoke Detectors Temp. Use of Power Final Utility Notice (Perm) _f -