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0304-126 (SFD)LICENSED CONTRACTOR DECLARATION' •1 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 CA13 WIN 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 .,kith licensed contractors to construct the project (Sec. 7044„Business & Professionals Code). O I am exempt under Sections 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 Sgction 3700 of ,the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation insurance carrier W policy no. are: T 1 Y D, 1 4,01 'i Carrier .4 I.�,T13• i`I:I:d Policy No. f �•��• t8i,,-91 - (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 pFovisi�on�s. .Date: • 3.3Applicant 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 any permit issued as a result of this applicaton agrees to, & shall, indemn & hold harmless the City of La Quinta, its officers, agents and employe 2. Any permit issued as a result of this application becomes null,and voi work is not commenced within 180 days from date of issuance ,of. s permit, or cessation of work for 180 days will subject permit to cancellati I certify that I have read this application and state that the above informatio is correct. I agree -,,to comply with all City, and State laws relating to the buildg construction, and hereby authorize representatives of this City to enter •u f t_ the above-mentioned property for inspection purposes. Signature (Owner/Agent) / J '�` r.-�`^---•mow--•-� Date PERMIT # BUILDING PERMIT 0�(WA26 DATE VALUATION,6W/�� LOT (° r! TRACT 2 ,? A JOB SITE ADDRESS 80-573 VTA -SAV PTA APN OWNER CONTRACTOR/DESIGNER/EN (NEER >�trprtr�a�/}a�: x:i(ay��,r�.�'� ,�^��s� xJ',5�4C� y� y'(� (y{''qj •1 }`� d'F ic"Y r.�{:i 4+1i'i.i•. �-6t.{6ZYa .il t�l v,. iS/4id J.J If'1 +� LCIrye�URqRIFF, NIECE15i PAiaAD.1TS7M SCA 4x2211 PALM, DIZVM ' 92.260 (s =(Y) 72^•82• /3 (12:UA'r' 11” USE OF PERMIT .)MC#I.. FJ�i'Etd'.i1.".0 Vi=A.i V;L"r '(as ,T o - 3A. 1 'iv4, pmw- smt.,NRl� 1 1 f:.3 .tY- ► w4"6 P,+'.kWi, YV Ab.1.Ar:.1 't'ool,,, T,' A 0q r)*rzN*1"vVAV F'L.(M FIAE 'f3U,17 TO MUM'1A.' Z ISSpiVICF. OF SAME IPLA't3 1 'iy'PF . CUSTC':.Aa1 E; MISTRI C" ": ON 101S,7190 DF ''- i'I:`k,Gisf=i�.'iIS SP 6.14,1011) BY . aTA,I.r ATED1CTtiIS.1~GY C.G'A%Ta14.0r�_r�:rtfio. K PL.KH #,".` EVA k kTll : 1 r.? i -000-4. c?. y IS XRtC}nAA1C,A1.s Fiala' 10'a t9d3 I;� Z.1 G©tI St.tQ,itt� 101 -00,0 -4,2b -•43i' Q F� Gf d3 Ii-► kf? 10 1 e000 T W:.typC SAIRA �� CCtt'1:•i# , tfK71!'.E�W'�f F� . �t !!J a fi 000 -2,4't -ow. 1k.e'I.17 l0:j.,..ei00-4101a 000 D9,P nz.v �i�I'��k aa�rAs:�� �arj...• ��,a�sfi.t<�� . fact C 114 I31tltiljiC FU- _UP, - RUH Zi{r'.-000l445-. 00 i)° 2911441 n��.ai:'�.=1�,C'�Jr.�.€O�:n�.,'��11��.�'%:�i���'�l�.i�.',lei.'�''..f�ii��i��.lar::,�a. �'•%.i.{Q�'%.�3�'� 51 PRE-P!:f7K 3 I3.f�0 TOM MUM FLOTI k a�'iU�.'' 'M.?'iiJl: t'4ei,,2 .69 MAY 2 7 2003. CITY OF LA QUINTA ' FINANCE DEPT. RECEIPT DATE �;. BY, . �/ r D 0 INSPECTOR INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Underground Ducts Forms & Footings Ducts i Slab Grade Return Air Steel Combustion Air Roof Deck Exhaust FansAA 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 000, Final Final . BLOCKWAI 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 APPROVA Gas Test Electric Final Waste Lines Heater Final Water Piping Irv,Plumbing Final Plumbing Top. Out Equipment Enclosure Shower Pans O.K for Finish Plaster Sewer Lateral . • Pool Cover Sewer Connection' Gas Piping Encapsulation Gas Test Appliances Final ELECTRICAil OVA M WFA 74 QJ F1 W; =M Notice