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0002-441 (RPL)I _ LICENSED CONTRACTOR DECLARATION. I hereby affirm under penalty of perjury that,l 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 20( 275706 Datey'' Y"� Signature of""Contractor �` %rr 4/ OWNER -BUILDER DECLARATION I hereby affirm under penalty of perjuryThat 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). '. _ , . . () I am exempt under Section ; B&P.C. for this reason Date Sighwm 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: Carrier' 1.}' Policy No. ' (This section need not be completed if the permit valuation is for $100.00 or less). O I certify that in theperformance'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 th Labor Code,,l sh II f . rthwhh comply with'those proves ons. Date�r Applicant .: /"✓..%". Warning: Failurelo<,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'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 purposesr` Signature (Owner/Agent) fl �' `'� Date i s n r ' . BUILDING PERMIT PERMI'OII�+ ; ,� DATE j VALUATION S,j61)4)0.04) LOT TRACT (r A JOB SITE 79 CALUE, VISTA V VERDE APN r - ADDRESS OWNER CONTRACTOR/DESIGNER/ENGINEER ,3:.'..'^^a, C:ON,C'T,'::; fir':%,',":. ' /7-9013 XVT14(Ji3 OF lHi.STF TES 4163 k ERE Z RE). PAJLAn DESE'Itf CA 92211 CKME,DRAL QW, CA. 52234 1� C13LIM 69 USE OF PERMIT POOL AND/OR SP.A. tOVIJI. - WA f N"L -A d1lCttii 4SAisR1'QS �1 MA L BE _ihi N.i ACE tt-i' PiE PLAS`iQf 1tvS.PWjr10NJNVESi`1G.Kf1 N Ff;X ASSN::,%.SHO PFR 97 97 U.et. c. §M.5 til, c wolm i3wtiN W1,17-Iour sulmoF.PiCy nw..,"..A'f r, POOL, LS ' EMMATED uC?' k OF CUPS s QUCT! X F PEAJAff FEF SUilaAI.M' :. I'LA:NCHECK FEE rcltf'S ql'c 'I'jc?v FEE. t,fll.fiilll-4.l.-ft�i0 $3n2.00 x44a'3r IAldlf,;AL Fal 7 -- POCIL 101 01nl 92,1-00 ILECI" ICAL t FE— POOL 101-0001-420-000 a4smo 1't, ii13c3f31yvCT;! E33 -- �°lJ9L lll.l fk30-='Ilv-©Oil t-"tCY'AT.: Cc�l;�r`IZ�J�..!'!C)N Aid s�iC,QN CE•��'.{.,1<' ���q,1g s, 1'OTAIr PERMIT PEES' Du K' NOW S549 IS , RECEIPT DATE BY-/ DATE FINALED INSPECTOR - ­�F INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE 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 BLOCKWALL APPROVALS POOLS - SPAS Steel Set Backs Electric Bond Footings Main Drain '3 - Bond Beam Approval to Cover Equipment Location Underground Electric Underground Plbg. Test 5 ' Final I 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 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) COMMENTS: