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0204-072 (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 533670 13.h`ic Date R' '` 2 Signature of Contractor J 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 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. (;wy 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 STATE -FUND Policy No. 07in".- (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 provisions) Date: -2 Applicant- Warning: pplicant 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, indemnity & 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. J Signature (Owner/Agent) �' °1 rr -" • ^-- Date 6j' ' 0 BUILDING PERMIT PERMIT# DATE VALUATION LOT 020"r* r* TRACT /f /4" L. 21 30125.1 JOB SITE' APN ADDRESS 50"1154 'L3Wf'b,ADA COURT 77.1-M2rt 11 OWNER CONTRACTOR/DESIGNER/EN 1NEER SMON.A HOMM SUNbRC3W COR "iRA1110A 77.564 COU.91, Y CLUB D.R.NE9 #) 3-7 17.645A COM ff CLUB DME sSUECE 1, 50 PXM D17.,9VAT CA 322111 PAL iti�'F�2`l' Cil g27,050 (764)77Z-8224 CBTIN 1137 USE OF PERMIT WGUY VANUIly, D•5blstU.:i91a VVI. 10f 21 pLJVNt 2R. PERA41`i' l:e0ES 140T IINC3, UDE 1; l.0CX WALIA P001% SPA OR DRIVEWAY.APPROA.CK 7M, PLAW CUFXiK FRE 11 :r)U ;i",101q FOR AWILTIPLE I3SUt-WC9 OF SA,14E PLAX1 TYPE CUSTOM C(3NMUCV011 ftl4KOP Sr Pf; RCHIP.ATIO 133.00 SP GAR.A01YCARPORT 66:1.I50 Si: A!rb7.iyiG4.3lAT,Ad:.D hi4.+'VsY.6 OF 0011 WI UCTI'JJ'.ltl 2.07=70 PERMa FES. 9Ub& WY CONSTRUCTION FEB 101.000.418-000 VLiV9 CHECK FEE 101-000-439,319 W. MECHANICAL 101-000-421-000 $.104:00 ff.LLa',CTPJCA1, PEE 101'000 -420 -OW $133.56 PLUMMIC VER 101.000.419-00() $10,00 STRONIJ. H0710N ITE - RFXID. 10.1 -OW -241 -000 $".Wj GI`1.1MM ISO, 101.000-423»000 8200 D T'`t ELOPER 1dtA.PACT ME. X1,90?.flE7 AST I'N P(lBLJC PLACE - fE.'SIE 2,170. 00.4 5-0ice Sly, d SU8 -TO TAL COXMOMIO1a)'..A h PLAN GM+":.'K. S ,59',".73 ------------ TOTAL Mdar FMISDUE, NOW t RECEIPT DATED ', ATE DATE FINALED /V o z INSPECT R E L id 1.31. .� 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 „/jp F.A.U. Framing /- p Z_ Compressor Insulation _ •�j �_ 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 POOLS - SPAS steel Set Backs Electric Bond Footings — ,?•y — O Z Main Drain Bond Beam _ — rim— Approval to Cover Equipment Location Q Underground Electric Underground Pibg. Test Final Gas Piping PLUMBING APPROVALS Gas Test Electric Final Waste Lines t��'� U 6� Heater Final Water Piping Plumbing Final Plumbing Top Out Equipment Enclosure Shower Pans O.K. for Finish Plaster Sewer Lateral Sewer Connection Pawl Cover 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) 1 7 t7r COMMENTS: