0205-103 (RR)�y 't".I herebylaffirm'under`penalty of perjury thafl-am'licensed'under provisions oft,"'
'Chapter.9 (commencing with Section 7000) of Division 3 of the Business and,.
tV, b' 'Professios Code. and nalmy License is In full force'and effect.
W
Lu License it ..9 ` Uc. Gass r Exp. bate.
16 P gle _~ Signatureof Contract
OWNER BUILDER DEATIONM
H W `^ C hereby affirm under penalty of perjury that I am exempt from the Contractor's
co)Lltrense.l aw for ttie following reason:
Z ( ) 71,'as Q, {Kir`of tFie property, or. my employees with wagesas their sole
cornpensation,,Will do the'work, and the.structure is not intended or offered for, -
sale (Sec✓7044; Business 8 Professionals Code): '
as owner of'the property, am exclusively contracting with licensed
'contractors ro, construct the project (Sec. 7044, Business & Professionals
.7Code). " a
2 O, ( am exempt under:Section, `, B&RC. for this•reason
Nb -Date,�-Signature.of Owner'r `
r0�'
4 WORKER'S COMPENSATION DECLARATION
C) Q �, 7 hereby affirm under''penalty ;of' perjury one .of the following declarations: .
r I—, O • �(') 1 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 pe rmance of the work for which this permit is issued.
-. Q -U ) Vhave ,and will maintain workers' compensation'insurance, as required by '
Q V, i on 3700 of the•Labor Code, for the performance of the work for,which this
a M Fa— permit is issued. My workers' compensation insurance carrier & policy no. are: ,
Z r r ;S9'.d TItAMD s; T, Policy No. O�t4• QQAS2441
..7 co
(This section need riot be completed it the permit valuation is for $100.00 or less).,
O i certify that in the performance of the work for which this permit is issued,
,1 shall not'employ any person'in any manner so as to become subject to the _
Workers' compensation iaws',of .Califomia,'and agree that if I should become
subject to the workers' compensation provisions oaf Se ion 3 0 of the bor
3 f Code, al forth 1th comply with those provis�dfi ;�
! Date. 't ',Applicant
'kWarning: Failure to secure Workers',Cor4ipe o coverage is unlawful and
shallr subject an eriiployWto criminal penalties and civil fines up to $100,000, in
additlon'to the cost of compensation, damages as provided for in Section 3706
s of,the Labor•Code,'interest and attorney's fees.
:IMPORTANT Application is hereby made to the Director of Building and Safety, ,
j fo`r a�permit subject to "the Conditlons and' restrictions set forth on his
application, ; ' ;
1, Each person upon whose behalf this application•is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit Issued as a resultof'this applicaton agrees•to, &shall, indemnity
' & hold harmless the ;City of La Quinta; its officers, agents and employees..
y, 2. Any permit issued as a result of thls application becomes null and void If
{ , work is not -commenced within 180 -days from date of.Issuance of such
permit, or•cessation ofywork,for:180 days,will subject permit to cancellation.
I Certify, that I have read this application and -state that the above information is '
• /correct. I agiee•to comply with 'all City, acid State laws relating to -the building',
tconstruction; and'hereby,authorize'representatives of thit City to enter upon
`the above-mentioned property for Insp loci purpo '.es x ;
Signature (Owne`r/Ager$) +` Date
iDING=PERMIT.�
DATE VAWATION �.' ui t t' i O�Ywf TRACTA x;�
r
J 5
_ i •. f -i+• FF' a` a .l. �._�.
JOB SITE ��yy ■��a �r+�}'��`{{
ADDRESS •�7 �lA41.7�!•iM.' r .. .�,� _
APN a ,,� -3 a
w''4. , ..o .k'.
OWNER, * t s K
. �� • +,
CONTRACTOR/ DESIGNER INEEFJ
0
��,�jNj1�/��)��j��ty.Jyi(.
PGA..
PGA '�.JYF:;i.WALII .�5`--*�" R
.'y��'y+(�y
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.i �'•ni�+YJV �•O�YIAu..•/wrtM✓.�•i', �'•� O1! -}I !`•.
P.Q, BOAC 1080• •
�7�55:A�d`F1CAYrY)
LACI A
CA7'1 1i.
R CYYiC • CA'912262
(760)3256-9111 CBU 46i 1
USE OF PERMIT
M11=I? VFITILCLASS A UATERRIAAt.S• H2.W. !*A Sd•421 t
rW 11831:"7 OAK HIE � a
VALUATION
3��;f IMAT'� COST OWN' �"•t�►1�i5T1�CJC�ON'
29A),
��.�r �•��p���
PRiJ7�lA F 911711 CiJ RY
R=0041? Va 101.000.418.000 $30.00
MAY, u 94(101*
WYOFIA&IkA
°
FINANCEDEPT
WJPATOTAL CO MWX.FilikN' C ..CK
LM Ffltl44AU) P=
ftoo
TOM Mthlff Mg DUE >' W
RECEIPT,
Dl�E
BY
DA�F�q
I ECT R
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pey+.( ��rf V Eti—:`•---„��---;..�.. ,.•--•'�_..<- .xM1 ' a_...�.`.�:J....�a l 7 i$} 'p..14+---:_'.._�,' . ��..��—'��...41—;��..._....�.. �_, �_..�.,_..�,a._. -_. _. _. ,_+_:"._.._4•.._.. •!._ ' +•
g�4
I SPECTION RECORD'
OPERATION TE
INSPECTOR 'OPERAT!.0N DATE INSPECTOR
.-BUILDING APPROVALS MECHANICAL APPROVALS
set Backs
un&nmwW Ducts
Form & Footinp
DUCIS
Stab Grade Return Air
Sted Combustion Air
Roof Dock
Exhaust Fans
OX to Wrap FA.U.
Framky
Corepressor
inn-tation Vents
Fhplace P.L. Grift
Fhplace T.O. Fans & Controls
Party
Was Insulation Condensate Lines
Party
Was Firewall
Exterior UM
6 '51 W 1
BLOCKWALL APPROVA
Steel
to Cover
I Location
and Electric
PLUMBING APPROVALS Gas Test
Electric Final
Heater Final
Plumbing Final
Out Equoment Enclosure
OX for Finish Plaster
Pool Cover
POOLS - SPAS
I Gas Test I I I I:--- I
I AWlances I I I I I
COMMENTS:
ELECTRICAL APPROVALS
TemD. Power Pole I I
I Main Service
I_Sub Panels
�Aerior Recx
G.F.I.
Smoke Detec
Temp. Use
Final
Utility Notice_