0311-109 (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 # Licc. 7Clas1s{ Exp. Date
746198
n`'
_ — 110
Date /I- of Contractor
OWNER -BUILDER
I hereby affirm under penalty of perjury that I am ekempt 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
S4 tion 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:
Gamer 'SyATE rU3.1D Policy No. (46-01000923.21-02 '
(This section need not be completed if the petit valuation is for $100.00 or less).
( ) I certify that in the performance of the tork for which this permit is issued,
I shall not employ any person in any ma her so'as to become subject to the
workers' compensation laws of Califorv, and agree thaM l should become
subject to the workerompensationpo�lslons of Section 3700 of the Labor
Code. -1 shall Jo,rt$w.Ltbi vmDly with thos Drovisions..w--M"
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 applic 'ton and state that the above information is
correct. I agree to comply with �frCity, and State laws relating to the building
construction, and hereby aut . ,Ii a repre'sentatiXe of this City to enter upon
the above-mentioned prope or nspection purposes.
,y3igrWure (Owner/Agent) °" Dale_
BUILDING PERMIT PERMIT#
g
DATE VALUATION LOTa TRACT
It M40 12 ELKIIS
JOB SITE
ADDRESS 7`x-'730 C.r �+ K'11�?lt 0A
APN
773,-1
OWNER
CONTRACTOR/DESIGNER/EN (NEER
ROY' SCHMERT
A. & M CO:MiJ'C'S.'lON
791.025 IASAN CLARA :.
78-070 CALL,L CADIL
LA QUI14TA CA, 92253
Z.,AQUINTA CA 922.33
(760)564-4832 Ckl 4 626
USE OF PERMIT
42 Lig COMBO ION RET/A Xf14(` 16 t'',VM:OZN 7AFALL AND 80 LF & SLOC
WALL, PER, ORCO DETA11..2001. C9C .
6 FT. WAIL 122.00 I.F
k8'l3 A'I'M) COW OF CONf�`.�UMOIq
3,MAW
CONSTRUCTION FEE :. 1.41-000418-000
NOV 14 2003
CITY OF LA OUIWA
FINANCE DEPT.
r. A
atm- -TOTAL. COMMUc:;7:10)ff AND �3. AAt C,fS
�G3.f�U
LFM PM -PAID FFXS
50100
Pla,WNW. VKRS DM, 11fsL?'W
WAK)
RECEIPT
DATE
/}.
BY
DATE INALED' INSPECTOR
• . U r,�(
/af• t
/l�ld_;
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 Wail insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
• Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS .
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final l p - U
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
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)
.COMMENTS:
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