9602-124 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9.'(conimencing With
Section 7006) of Division 3 of the Business and_ProfessionalsCode, and my
License is In full force and effect. 3y -l. ,,
License # Lic. Cl ,.Date/
/Date 414,1- SignatureofContradtor
OWNER -BUILDER DECLARkIC;e
I hereby affirm that I am exempt from the Contractors License Law for the
following reason:
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).
1, 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
1 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, Yhs'provided for by Section 3700 of the, Labor Code, for the
performance ,oith6 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 sectign need,not be completed if the permit valuation is for $100.00 or less).
.( ) %, 4
I CeMOAin "We performance of the work for wh&M'�NMQ 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 tpe wo®reis' compensation pr6visibns oflSection 3700 o-f'the Labor
.4!
Code; I shdlI fortiriwith comply1wisw
th thoptovh§ion9(
�Date: '',/ A�////:/ Applip/ant /05, x--. V-`�,l 1 4
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 -be ' half 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,.a
pplication.a ees to, & shall, indemnHify'
Q
&hold harmless the, City of indi Ws, its `104671is, 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 Sta te laws relating to the building
construction, and hereby authorize"'representativ7s,of this City to enter upon the
above-mentioned property for inspection,purposes.,
Signature (Owrier/Agertin4�-'//�//�.�e1,2, f:11,`1)4e1V1 Date 4
iI Ir / . V. - I - I ..
ALCM
PERMIT
BUILDING PERMIT
DATE Z12300
VALUATION 5-7,24,8
14. TRACT 2614-9 MAS' 1 -
JOB SITE ADDRESS-
014 SGUI LA.1b
APN
OWNER
CONTRACTOR
RANo4o cAMvRAM.)
1191697 COUITTIlly CLUBV%.. I
56-1,10 Pd iii ,'BERMUDA
DUNES, CA 92201
LA QTJINTA�, CA 9225a
(6.19)3454755 cm# ' 19,69
DESIGNERIENGINEER
20, C1 Rrlloruvr,13 1111KK -
USE OF PERMIT
..;INGLE FAA'�ULYD, ELLING,
lie ek ftat t4
THE HF -Mr C011,FC116N - PG -A: WFST
,rA(,-,L-
PT.AN I -B
FEE DESCRIPTION
FEES
Cd,'TI'OA4 CON,3'fROM ION 716,53.00 SIF
P6RC111PATTO 302.00 SF
ciARArrdirARron 711100 31
M-CMAIED COST OF CONSTRUC-"ON
PERMIT FRE SUMMARY
PLAN CHECK n"F-.0-439-31' 8 8877.29.,
co-NSTRUCCTION FT -E 1,01-000-418-000 S-1,077.00
ME-CUANICAL FEE
ELECTRICAL FFE. 1,01-000-420-009, SI(A.69
PLUNIBiNc, HE
SWYNO MCG1010TE RES11D 101 -OW -211-000 $2148
01kADING1701 10.1ry,WO-423-000 $20.00..
-rNPRAnaticiruRE Fit 22"0(3-443-342 S4,91;7,98
A
SUB -TW -AL CONihkbCTIONAND PjAN cmck
$Z.105,73
U -SS PRE-PAIDPEES
TOT -At, PERUNCITIVRES. DVE NOW
S7,705�73
[RECEIPT
DATE
LED
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 f
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 Wali Firewall 01.1
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
Gas Piping
PLUMBING APR ALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping VPlumbing
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
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 DIV I'm
Utility Notice (Perm) Ej - I
COMMENTS: