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0401-014 (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. License # Lic. Class Exp. Date ` 656128 C5.3 MC C-3 T031/W Date Signature of Contractor f OWNER -BUILDER DECLAy�ATIONy' 4!,�, I hereby affirm under penalty of perjury that I am exempt p-fro'tFi'the C` ontractor'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. () 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: .099r STA11 G'O MPUN3ATI, Policy No. 040-41104-2004 (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: Applicant Warning;'Failmre to secure Worker�Compe sation.covera a s=unlawful and shall subject an a employer to crimipal p n6lties-and civi fines `to $T00,000, 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 pursuanVto', 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 buil"ding construction, and hereby authorize representatives of this City to enter upon the above-mentioned property forinspectionpurposes. Signature (Owner/Agent) �✓" Date " BUILDING PERMIT PERMIT# IV:01 _0A11 DATE ° VALUATION qt�,1 3. LOT 4.42 TRACT o JOB ADDRESS r✓N"'�' )0 -VM 11'A A vdefLN APN OWNER CONTRACTOR / DESIGNER / EN (NEER I)OLL 13IW`1Aiti+IR011 WC Cl�r1°'t>1�N���1✓t71�1 91� �� �'��'� TRA.1� �(3P -7*117.1 AU 1^i W A'I Q40 01©0 $6-100 AVE NI VE 54 RPL.fdl.iJVINER'f CA, M60 COACHRIJA CG.A,. 92'L$6 (760)3W-9222 (T; -.. if 100355 USE OF PERMIT r-OOL A�OROPA QU.t,1U4U ;SY& i-VtYbY : �$ i.dr X WALL CITY 14_5`I'1 NDAIT, ALARMINBARRIFM Ulid , BE 114 &WE PPIOR TO PPIVI1.AS 9111fC.,#I'ECT1OT4. POO1, A IDIOR DPA ?e V90.o4 -w J ,it'4`, WFALLL 11F M 2!,= Coyr W!, CONS-M?C�MON 18,1. .2.5 stfoblaty RAN MCK. PI's'�, CON4TRUCTItF'NW? ii�I- flf1 <i1s -�C3Q �iSR.IJ{7 MECHANICtAL IEE •- POOL 101.OD04,21.000 42koo L'LEC:aRICAL'17M—POOL 101-000-420-000 $45.00 101-000-419-000 01100 OUS-i`(YrAL Cf,31viS'.E',i?IJCI.tT U AIM P -LAN CMIX &422,70 tM1413 rrlll.�PAW FEW W.00 . "'— - .� _�.•� _ YO AL MWE F�a. 5 DVE NOW $422, Iii 1, RECEIPT DATE BY "` DATE FINALED INSPECTOR INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE I 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 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 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 COMMENTS: Final Utility Notice (Gas) ELECTRICAL APPROVALS Temp. Power Pole Underground Conduit Rough Wiring Low Voltage Wiring Fbdures Main Service Sub Panels Exterior Receptacles G.F.I. Smoke Detectors Temp. Use of Power Final Utility Notice (Perm)