0204-074 (SFD)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
333670 B htc W30/02
Le `' " ' f,. Signature of Contractor!�`�
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
( ) 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 fog which this
permit is issued. My workers' compensation insurance carrier & policy no.`are:
Carrier STATE FLMD Policy No. 107152
(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
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with=those p`r,•ovisions.
Date: '' °r ..Q?.Applicant j7,
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 above-mentioned property for inspection purposes.
Signature (Owner/Agent)`"-...-... _ Date
BUILDING PERMIT PERMIT#
DATE /VALUATION - LOT (Y204-014 TRACT
j�;� s22UtUt9� 0 2.4 �t�laS•1
JOB SITE ,tC y �*Te�y/�/�Lry�
ADDRESS �i+ 75 C�^'d0�.t#A�iAt%!A C9,0 d
.7
AP�INEER
OWNER
CONTRACTOR/ DESIGNER / EN
SPMONAHOMW
SMI:ROSR CORPORATION
7M64 COQ NT.RY CLUB DIUVE, 6137
77.645A COUIS MY CUM DRra SME I!"C
PAIN DYMERT CA 922111
111PIM DRS'EF-cr "A 92260
(760)772.8224 Cluh 1137
USE OF PERMIT
XW0I.T? 1 aAW_Y DWf1X1N(.3
SFO - LOT ;3 PLAN 3R . PERMIT DOt*,S NOT 111W ,fM9 HLOCX
WAl. IA POOL, SPA O DRIUVAYAPPRO CH, 71% PLAIN C.HFICK FU
.s -EDUCTION FOR MULTIPLE I1q_'3U ,%14C E ON aAYI E .K.A.M TYPE
CUSTOM i ONSTR,UCTIaP UX Do SP
POI7.CHMATII) 116.00 SI:
C ARAM CARPORT sa"OIN s
CONSTRUCTION -1 Pals 101-000-418-000
PLAN CHYCK FEE 101-060.439-318
IMCHMICAL M 101.000.421.000 $1021so
LrLE WCAL IT8 101-000-42.0-000
PLUMBINI('I 9 EE 101.000.419.000
STRCiM MOTION FEE -.RZ31tV 1.0! -000-2131-000
Mfs.,,'flW FEE 101M000-423-000 WIN
LIEadELOP.ER IMPACT YE $1,907.00
ART Iia' PUBLIC PDMS - ME 271.000.446.000 03
Ia t.
_ VM L*.11J aY.fll3673.8} A'.Tio4+AY DUE NOW
VC!'"9'LOaI}'
C
`
RECEIPT
DATFf �` /I
BY
DATE FINALED
INSPEC
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
p
F.A.U.
_
Framing
p -Z_ C
Compressor
_
Insulation
�� �_C
Vents
_
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
Steel
POOLS • SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
�� c3 z
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Shower Pans
_
Equipment Enclosure
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
Utility Notice (Perm) �,
COMMENTS: