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9906-162 (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 ID/�:aJ.i7 iw-33 / 0113112M teI_'_'-'?5:t Sign ature of Contractor�'r Z, 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. STATE FWsV 1421,1=-91J (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 worklps"compen sation laws of California, and agree that if I should become su2ect to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions. tate: ��. - 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. 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 Bove mentioned property for inspection purposes. ,,Signature (Owner/Agent) , �<%� Date •!- 2 BUILDING PERMIT DATE t)&2,2f 1"VALUATION 513,442.00 LOT JOB SITE ADDRESS 4& 142k146 C:. UE MOWS OWNER LAGfM A DE LA -PAZ 49-100 VISTA LAGUNA .LA. QUINTA CA 9M3 USE OF PERMIT GENERAL WFLEANG Rr, ROQF FROGIF PERMIT /t 40906-16 TRACT APN CONTRACTOR/DESIGNER/ENGINEER vEwMti i.N!tFIC ROOF fN 10 346E .LA CAM:PANA WAY PALM SPRINGS CA 92262 (700)416-5M CI3L?; 4293 1.3,442.00 LS EPS-fINIATED C'AS'T OF CONSTRUC"'l 01411 13442,00 PEIRAT V01,1 I.WMAalARV 1t 3KC)OF Fa 101-0004 i N-000 $30.fitj SZJ&TV17AL, C ON;S 1'ZTU(`"?l'TON AND PLAN CHECK $Gfl.Ot� LESS PRC -PA D KES SR00 RECEIPT DATE BY ! ^" / ,DATE FINALED INSPECTOR INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Underground Ducts Forms 8 Footings Ducts Slab Grade Return Air Steel Combustion Air Roof Deck Exhaust Fans O.K to Wrap F.A.U. Framing Compressor Insulation Vents Fireplace P.L. Grills Fireplace T.O. Fans & Controls Party Wall Insulation Condensate Lines Party Wall Firewall Exterior Lath Drywall - I . La h �O Final Final POOLS - SPAS ' BLOCKwI1 AlPROVALS Steel Set Backs Electric Bond Footings Main Drain Bond Beam Approval to Cover Equipment Location Underground Electric Underground PI . Test Final I Gas Piping PLUMBING APPROVALS Gas Test Electric Final Waste Lines Heater Final Water Piping Plumbing Final Plumbing Top Out Equipment Enclosure Shower Pans O.K. for Finish Plaster Sewer Lateral Pool Cover Sewer Connection Encapsulation Gas Piping Gas Test Appliances Final COMMENTS: Final Utility Notice (Gas) ELECTRICAL APPROVALS Temp. Power Pole Underground Conduit Rough Wiring Low Voltage Wiring Fixtures Main Service Sub Panels Exterior Receptacles G. F.1. Smoke Detectors Temp. Use of Power Final Utility Notice (Perm) LICENSED CONTRACTOR DECLARATION uj I hereby affirm under penalty of perjury that I am licensed under provisions of I— . Chapter 9 (commencing with Section 7000) of Division 3 of the Business and 04 LLIJ Professionals Code, and my License is in full force and effect. License # Lic. Class Exp. Date o W in C�� GOWN N- P - Z � /te-`$+ Signature of Contractor:," ,Z� � (O 0 ri r U CD OWNER -BUILDER DECLARATION LU LU I hereby affirm under penalty of'perjury that I am exempt from the Contractor's ~ d License Law for the following reason: Z ( ) 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). cY) () I am exempt under Section , B&P.C. for this reason U) N Date Signature of Owner ON U—d. WORKER'S COMPENSATION DECLARATION Z o cr I hereby affirm under penalty of perjury one of the following declarations: In H' O () I have and will maintain a certificate of consent to self -insure for workers' X W compensation, as provided for by Section 3700 of the Labor Code, for the m' J Q performance of the work for which this permit is issued. Q(� ( I have and will maintain workers' compensation insurance, as -required by O U Q Seton 3700 of the Labor Code, for the. performance of the work for which this n:. v Z permit is issued. My workers' compensation insurance carrier & policy no. are: Cartier Policy No. 6c STATE FUND 1424240-95 r` O g (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 shalln Iremploy any person in any manner so as to become subject to the worke compensation laws of California, and agree that if I should become sub' ct to the workers' compensation provisions of Section 3700 of the Labor C e, I shall forthwith comply with those. vis ons. ate: , _:. , Applicant -, 4Z � s 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 4 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 e�Vlp & 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 carptlation. I certify that I have read this application and state that the above infomiation is • correct. I agree to comply with all City, and State laws relating to the building constru tion, and hereby authorize representatives of this City to enter upon the ove-mentioned property for inspection purposes. Zignature (Owner/Agent) _ %�Date 2 m - PERMIT # ,BUILDING PERMIT DATE OWZV-I"VALUATION $13,442.00 LOT TRACT JOB SITE 4&142U48CALLS SERMA) APN ADDRESS OWNER CONTRACTOR/ DESIGNER/ ENGINEER q L.AOLN;A DE LA PAZ �t9SWRN PACIFIC ROOFFING .48-100 VISTA LACAJNA 3462 LA CAMPANA WAY LA QUINTA CA 92233 PALM SPRINGS CA 92262 f700)4% -,M77 CHL.n 4293 USE OF PERMIT GENERAL BDTLDING RE-ROO RBZ00r 13,442.00 L3 FSTINIA 'ED COST OF VMSTRl1C 0N 13,442.00 PERAUT SEE SUN ARY PJAOOF FW �l IF—r- SSU&T . AL Cc, , ' V770N AND PLAN CHECK $30.{}0 LESS PRE •I*EES $0.00 4'ffAL PERMIT FUN DUC NOW 00.00, / r CEIPT DATE Nj �i BY ` r' ],DATE FINALED INSPECTOR ei�