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: