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0112-129 (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 656 ] C53 :ECIC' �8 _ 1 �° 31 /W Signature of Contractor'''w �% 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 e7ye with wages as their sole compensation, will do the work, and the E�ucture,Ap not intended or offered for sale (Sec. 7044, Business & Prof essionals,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 cgrSsent to self -insure for workers' compensation, as provided for by Section 37o0;.of the Labor Code, for the performance of the work for which this permit is issued. �(y) 1 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 Policy No. (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, .l 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 fort with comply with thos provisions. /Date: Applicant- Warning: pplicant Warning: Failure to secure Workers' Compensation coverage is unlawful and shall subject an employer to criminal penalties and civil fines up to $100,000, in addition to the cost of compensation, damages as provided for in Section 3706 of the Labor Code, interest and attorney's fees.. IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the'°conditions and restrictions set forth on his application. 1. Each person upon whose behalf.this application.is made & each person at whose request and for whose benefit work is performed under or pursuant to any permit issued.as a result of this applicaton agrees to, & shall, indemnify & hold harmless the City of La Quinta, its officers, agents and employees. 2. Any permit issued as a result of this application becomes null and void if work is not commenced withinj180 days from date of issuance of such permit, or cessation of work for 180 days will subject permit to cancellation. al certify that I have read this application and state that the above information is correct. I agree to comply with all City, and State laws relating to the building construction, and hereby authorize representatives of this City to enter upon the above-mentioned property fdr inspection pu/r�poses. i Signature (Owner/Agent) 4h4p Date f ` BUILDING PERMIT PERMIT # DATE /j/} VALUATION LOT ®�$•t11�� 'Y) TRACT ' ('7 ':' X1'1 .../° i36i•�p1d�d.7o111il JOB SITE ` APN ADDRESS 4"70 VVDA FS =,LLA OWNER CONTTR/A1C�TOfR / D�E+�SI/GrNyER / EE/NbINFFER ry yy y^�> g � q �y y q ��?�� y AiJ DESN' �� DE �i.L:Srt�t',3N' E J. }} p� !` p�7 CLAL..T.C��iCd' 1A POM 6�� ►')1,���`d� CCO.0 MA Yi0J VO BOX 1716 74.723 a ONO DR1'l E, SUM'ie AA 1AQ(UNTA CA 9225: RAi,1+r:C: EBERT ; CA. 92260 (760)340.9000 M-4 0035 USE OF PERMIT POOL AMOR 3�'A PCatD1./MI}A 808 WK IZa;t•:8.190) A.Lfi.[ e'1-+'SISARYti'.IMS SHAL1, fi !1d 1�L.ACL� AT I3,F'tt<� f�I�A T°Ei II SFL I'.tg1d, POOL Gi'PItAl NT ENC:I.•OSUTRE'NOT IN. CLi3DF-D V'Al.UATION 2x, +0.00 W � 98TYMA"M COOT OF CG3NSTRID'CTIM V.Wbo IM! MMT IME aumbLARY 111,AA CHECK FYfZ 101-000-439-.418 . 5106,25 CONSTR.ut"t IO14 M9 101 -000-419-000 $275.00 MECHANICALFFE.•-n,S004, 101.000.421.000 S�AQO it D 1XT&I[CAi. FEI: POOH 1'I.t11M111'i�1'�► ?,I's ;P001,101400.419.000 � •; r � $7�,` M 0EC 1 2001, P�.T ' X 'Sp ,xvrLpma mmNkY 167i2- RECEIPT DATE,r BY : •tE„— DATE FINALED INSPECTOR me 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 POOLS - SPAS BLOCKWALL APPROVALS Steel Set Backs Electric Bond Footings Main Drain _ Bond Beam Approval to Cover Equipment Location Underground Electric F 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 j —ala— 0-2— Sewer Lateral Pool Cover Sewer Connection Encapsulation Gas Piping Gas Test Appliances Final -� 1 COMMENTS: Final Utility Notice (Vas) ` ELECTRICAL APPROVALS Temp. Power Pole Underground Conduit " Rough Wiring Low Voltage Wiring Fixtures Allain Service Sub Panels Exterior Receptacles G.F.I. Smoke Detectors Temp. Use of Power Final Utility Notice (Perm)