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0311-023 (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 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). ( ) 1, as , -owner of the property, am exclusively contracting with `licensed contractors to construct the project (Sec.. 7044, Business & • Professionals Code). r . O I am exempt under Section.- , B&P.C. for this reason DateSignature 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%rrby 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 Se tion 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. %Af3lsRT T MUTUAL F Policy No. �?aPa02w91?2 s0)q)•I. (This section need not be completed if the' permit valuation is for $100.00, or less). - ( ) 'f 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,l should' become subject•to the workers' compensation provisions of Section 3700 of the .LaboIr Code, I shall forthwith comply with those provisions" , ;✓. Date. a o ;? -= Applicant r Warning: Failure to secure WorRers ,Co pensation cov�rag'e Is nlawful and shall subject an employer to criminalrpenalties and civil fines up to $100,000, in addition to,the cost of compensation, damages as provided for in,Section 3,706 of the Labor Code, interest and attorney's fees. IMPORTANT' Application is hereby made.to the Director of Building +d Safety. for a permit subject to the. conditions and restrictions set fo IjhJ o' n his application. i ,Id r 1 Each person upon whose behalf this application is made & each per`son atjo� whose request and for whose benefit work is performed under or ursuanf to' any permit issued as a result of this applicaton agrees to, &'shall, indemnify lI & hold harmless the City of La Quinta, its officers, agents and a ployees..FIN 2. Any permit issued as a result of this application becomes null a'r�?d-if'— work is not commenced within 180 days from date of - issuance of such' permit, or cessation of work for 180 days will subject permit to cancellation: I certify that I have read this application and state that the above information is correct.I agree to comply with all City, and State laws relating to the building construction, and hereby authorize representatives of this City to enter upon the above-mentioned property for inspection purposes. �d�,, Signature (Owner/Agent) �'� Date-.//./- .i BU ILDING PERMIT PERMIT#q DATE VALUATION r191 M7 .LOT �.V„i'�• TRACT JOB SITE ' 'li'�fi `�1 j�a �ra��i� JAPN ADDRESS OWNER ' CONTRACTOR / DESIGNER I NEER r Jt'....J.�xer �J�4� il'9� .7• ��:l. WlUA3M1R1ro~i .. 12;1.:T"'i2£w VvAA''V(t1 0,1UO .._... t?!' 7:Iuu di fa T" C-iA, 9YZ60 RA3 �tM 3:1r IMI, i,' } 4.11, 5+'". 260 USE OF PERMIT C11•a AS h[N"Aii l.:t,�UrrO. �.C141f l.�a^t ll..•B.Wl.4i .. til Sf.. [�.lg%pD�Atl 1• BLOCK B� O.CK 0[..�llr.. A. P0014. SPA OR l•��J"iA Y 3.`��1{� i_ M'�Ci�k:J ^4.t iJ7, R�,7�F+: JUDI !£�-P. I�t;•i ION 3'L). i•'Is:AN f3f$ACK-: pm? 01jr..`1'U issl)ANCE, 0E-, AM. .rvp? . CUSTOM Ci %M rRUC rJ0_111 .:. U12.00 $F WC11 Gs1fF':f ; if:? 433.00 S? , MUM l?�1 CON �vi��7tT�S ,6Yir XONSTRUCTION FZ1? Q33 -000-4 z 8N000 "olc 0e,tis) . PLAIN CHECK FES. • 181-000-4319-318 MECHANICAL .YEE I �iO3 . m""(%.Sa t0� 1Q,g3�tt>��3'�1 1ildl�Ed'�Gw;^4'4� Utl:�;e ��-M). .. �d�3;�3: , .1-00 S',tR.CY.fl(J M(*dT'ION Fr31 ,. t'i.i,9i1), Isii Cis 242-•000 $30.0 ; w o�;"M)I,':J'is.�i ?�tI•�1Clt��?S�,°S•CTf)0. W,flt3 . AAT Ikr 060445!,000 19.2003 dCi 41MAL M.c4m, Lam(: �f dlT ARDP.i.?', A„E —-44391412,3 ba LA ©UI,3T �fdS:E SEPT. Teo",. 4r•x RECEIPT ;, .DATE . BY " D T I D I PECTO INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVA MECHANICAL APPROVALS Set Backs Underground Ducts Forms & Footings Slab Grade Ducts "I "hill Return Air Steel Combustion Air Roof Deck au st Fans O.K. to Wrap v _ Framing r Insulation bLK OOW_ F.A.U. Compressor 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 Pibg. Test Final Gas Piping PLUMBING APP VA e.Gas Test Electric Final Waste Lines .� Heater Final Plumbing Final Water Piping ! _ Plumbing Top Out Equipment Enclosure Shower Pans O.K. for Finish Plaster Sewer Lateral Pool Cover Sewer Connection Gas Piping psulation Gas Test Appliances Final COMMENTS: 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) — � v