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9906-158 (BLDG)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 23573 %_3.� Diilr:ii( Pate - 7 i • � � '�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). ( ) 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: 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, 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 C9de, 1 shall forthwith comply with those.pr.Wions; VD'ate: ? � Applicant � `� _ ��� 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. 4 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 purposes: gf nature (Owner/Agent) /Ila Date BUILDING @P�pER�9MIT DATE 06122111I99VALUATION ,7113,442.00. LOT JOB SITE ADDRESS 4&NOWN 10 i.,t"A.1+JIC. +'tJllraRE®talAS OWNER,+ O7 K h E y ,a, A 48-100 VISTA LAGUNA i.A C11,alnj A. CA 922.33 USE OF PERMIT CslNFsit 11 RIliLE)WO RE-R(XV Zi:ERC <)J7 PERMIT # °��Oi►- DSS , TRACT'. \i 1. APN CONTRACTOR /�+DESIGNER / ENGINEER CIMIC MICI 3462 LA Cf1.i��tNA•3`iA WAY PALM ,SPRINGS CA 922,62 (70)4 16- 5877 CBLft 4293 1.3.4 32.0(3 LS ESTIMATED V.S71 OF CONSTRUCTION TION 13*442. 6 SUB-?f'C' YAL CO N- TRUC,`TION �.ND P?�AN C JEC K $30.00 GESS PRE -PAID }SEES $0.00 r^j%IBY FINALED IINSPECTOR INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Underground Ducts Forms & Footings Ducts Slab Grade Return Air Steel X 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 BLOCKWA 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 Encapsulation Gas Piping 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) 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.Cnlass Exp. Date t ,235717 C-39 .. 0� 3061 to /- 2 z `i Signature of Contractor OWNER -BUILDER DECLARATION 1 hereby affirm under penalty of perjury that I am exempt from the Contractors 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&RC. 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. ( 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: Cartier Policy No. . STATE FL= (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 worker ` compensation laws of California, and agree that if I should become sub ct to the workers' compensation provisions of Section370 of the Labor C96e, I shall forthwith comply with those,. ovi ions ate: Z. A cagn. Applicant _ 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 attomey'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 issuanee. 6f such permit, or cessation of work for 180 days will subject permit to cadtCeHation. 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 constructi -and hereby authorize representatives of this City to enter upon the ab a mentioned property for insgection,pururrposes. r� l *`:% gnature (Owner/Agent) Date 6' _Y--� . ����/ ;- BUILDING RERMIT PERMIT!/ ----------•------. __ DATE fW22I1"vAWATION '.$13,442.00 . LOT TRACTs,,4 .. JOB SITE ADDRESS 48-i"l14 CAUE SERANAS APN — OWNER CONTRACTOR / DESIGNER / ENGINEER LA GUNA DE LA PAZ WESTERN PACIFIC ILO(?FI110 48-100 VISTA LAGI—NA 3462 LA CAMPANA WAY LA QUIN'TA. CA 92253 PALM SPRINGM C.A. 92262 (760)41(5,o5,877 Ci3L44 4293 USE OF PERMIT GENERAL BUILDING "-ROOF RE fi.+QF 13,442.00 LS ESTU"TE D CWT OF CONI STRUC ON M4442•.ff PERMff FRE SliMiV "Y RMOOF FEE 101-OOD-4 i.8-*;1t)t! 3e).tx3 3 F R-61FAL CON LK- ROIN AN[) PLAN CHECK $X00 i LESS PRE-^AJD FEES $0.00 TOTAL PERMIT FEES DDR NO%V $30.t1U F' CEIPT,,, DATE BY DATE FINALED INSPECTOR � J