SFD (9907-034)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisi * ons of BUILDING PERMIT
Chapter 9 (commencing with Section 7000) of. Division 3 of the Business and DATE VALUATION LOT
. . "I oj,q"Zo
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
JOB Sn't
ADDRESS
49-56 &IONWANAWAV
1i nature of Coneactb OWNER
OWNER -BUILDER DECLARATION 1.11 G -D 13S E fC14. D L� V C, LOPNILIN.f*
I hereby affirm underlpenalty of perjury that I am 'exempt from the Contractor's..13c),x.1716
License Law for the following reason:
"LA, QUINTA
1, 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). USE OF PERMIT
1, as owner of the 'ipro - perty, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044-, Business & Professionals STNGLE FAIV17111Y DW8LUM
PERMIT#
9WI-034
74
APN
TRACT
:59.12
649-240-607
CONTRACTOR/DESIGNER/ENGINEER
SPARMS CONSTRUCC'nOTlY
79-295 RANC140 LA QUINTADI.L
CIA 99)53 LA QUMA CA 92753
God
I am exempt under Section —, B&P.C. for this reason S - LOT.74 PLINMIR 4 RMIT DOD 140T&C.Lum K WALL
Date'PL/W CHECK FEE IYUK'MONFORMULITI L6
Signature of Owner
I S SUANPE; OR SAME PLAN Tfn.
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one ofl following, declarations:
O I have and will maintain a certificate of conSent?o self -insure for workers' CUSTOM CON 1IM-.1710N
S 3,076.00 SF
compensation, as provided. for by Section 3700 of the Labor Code, for the 'POIWIHIP All 1.0 sr
perform.anc.e'of, the work for which this permit is issued.
�h I have and will maintain . workers' compensation insurance, as required by GARAQYJ0VtP0XT 69,100 SV
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:
CarrierPolicy No.
STATEF'UND 46 'is
13
(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 becpe-sub,'ect to the
workers' compensation laws of.California, and nd agree that if I shoul become
subject to the workers' compensation,provis) ons of,Se'ction 3.700 of the Labor'
CodeJ h - 11 fo7rthwith comply with those provisions.
Date- Applicant
,Warning: Failure to secure Workers' Compensation coverage is unlawful I d
shall subject an employer to criminal penalties and civil fines up to $100,006, in
addition to the cost of compensation, damages as provided for in Section'o 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application. is hereby mad'e to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quirita, its officers, agents 'and emplpyees:,,
vo f
2. Any permit issued as a result of this application becomes nulriat;d' G
work is not commenced within 180 " 'days from date of'issuanbe of such
permit, or cessation of work for 180 days will subject permit to caneellatiow
I certify that I have read this application and state that the above information is,
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-menti6n'—edi p�perty for i5$pectign purpes
/Signature (Owne,dAg_en) Date 6, �9
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ENTMIAUD 0 N
COMSTRUCT WN'MA3_101<W0418-000
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1101.000-41111-000
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101-000-42MOO
PLIAVIffiNG FEE
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$20
T-WHok STRUCTURE FEE .
225-000443-U2
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RECEIPT I DATE I BY DATE FINALED I INSPECTOR
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 Cv
F.A.U.
Compressor
Framing
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath eaj
Final
Final —
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Appr val to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines v
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)