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0211-030 (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 7776959 Date /I dG o '4- Signature of Contractor C// 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). " (.) Lam exempt'under Section B&P.C. for this reason Date s ` 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. NW),- 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. I,,1B1?1k1,y MZ}'ijA Policy No. A.ab�Iallfl€ d:3912.''t s (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'fo the workers' compensation provisions of Section 3700 of the Labor . Code, I shall•forthwith comply withthoserprov'sions. Applicant d�%- � 61 "' Warning: Failure to. secure Workers' Co ensation 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 fora permit subject to the conditions and restrictions set forth on his.h, application. j~ 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�f BUILDING PERMIT PERMIT# DATE VALUATION LOT A TRACT XrM JOB SITE ADDRESS rY APN 77-:�t dA OWNER CONTRACTOR/DESIGNER/EN INFER TOLL TOl.,L33YtOMOR{�3' INC, 73-121Ml"�." W 2,_g0'#1(0 73.121 X dD VIPa[Z.IN011,401Q0 -A LM DF,sn:r CA 922M :€-AIM;.31 2527 CA 92266 f;! 60)657/196.99 ;=1,4i 393 .11i USE OF PERMIT C o. T'x? 1'rj�WLY' r"Wrf,imG Sri) ,`'�jB1�'.r„g{�gPy}'3ChL��dy`i'hi3�a�7.. a�pi'`}t'•S"t�i08.um, ,�yy-Y}}.�3;Tf1.yI+,,�Ta"ag€��I7Iyi�;js7q.�p (131,0 K, @: AhFPsF3', ,!' 004 f�i A 011 P.+RIM �.�I,A•9.,T *�` FRIO.CtiC . MUM CMN'STItUC3ION V597.00 sp }�%3RRro&1�3y1�'P1CS �:��.00 S� MWAM CSJir''S}a'�" C4 o;f1s"`£Pd'(1N1ft��z.4St3 PURIT F.9L SUWA ARY CONSTPUCTION MY, 1.000 ry1ry011,C'tC0.41; q$1134310 �"�!!:r.�i.�l �Fli�.Clo`T.�'.� 8 F.7 !'"���-=i,��-'.•�1r�`i° ��5�`,fY�.lt XMINHICAL FEE 1x01.000.121.Oofj 1G9,3t9 )OXC ARICAf MY, ! t11 -000420000 P11�'d���ll3fl�`�wi� � '1f31n�fi4.�l�v�y�7 S�2i:�� .��j'PROC NICI IWpsa�+'a ION FEE . Ii,f;SM 10I-uCl0�241-Uf"i ' ��++:S5���aII.�/� 'tYR ACIM PER R t 101-000-423-000 d�8. oto -Y, „.. ART IN PU)�fLU Xwi.�AC - X� IY, r IOi 445.060 3151.34 T G1?t1] C 1 Q2'--ts��- 1 �3x,oaf�.t}f1 �iXT3-'�`Cr"C. �"C!'3aX'�1.er�;l"3:�?�i ��;t? ���r��J• �'1rTl".�+� ��,�:��.t1�1 �s,�3. T-13Fa?'A1X.a T?E��,`I •D . /, ` --� m�"�,tIUG:�� . ,,�idl .t1°A.YI,,bT•�•.L�'�l.�.I.b{.� ��'� J.i��� ?aTOYJ�M1\:.�i:!' 2 10 CITY ©F LA QUINTA FINANCE DEPT. RECEIPTDATE ,[By4 DATE FINALED INSPECTOR INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs i Underground Ducts Forms & Footings Ducts Slab Grade Return Air ' Steel Combustion Air Roof Deck Exhaust Fans O.K. to Wrap 3 F.A.U. Framing 054 Compressor Insulation p3 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 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 3 Encapsulation Gas Piping Gas Test ((o 2z Appliances Final ' Final 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 Utilitv Notice (Perm) COMMENTS: AX_ M��