0307-164 (SFD)LICENSED CONTRACTOR DECLARATION
C/) I hereby affirm under penalty of perjury that l am licensed under provisions of
F- Chapter 9 (commencing with Section 7000) of Division 3 of the' Business and
WProfessionals Code, and my License Is in full force and effect.
=) ch License # Lic. Class Exp. Date
LU
r` LU r
^o Z r Date _ r r ^ ,Signature of Contractor a ��'•� _ "" �'
J U CD OWNER -BUILDER DECLARATION
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) License Law for the following reason:
Z_ . ( ) I, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure isnot intended or offered for
sale (Sec. 7044, 'B usiness & Professionals Code).
( ) 1, as owner.°.of theproperty, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code). yr,
(") O I am exempt under Section B&P.C. for this reason
U') 1
N Date Signature of Owner
N
0)
Q '1N6RKER'S-COMPENSATION DECLARATION
2 Z I hereby affirm under penalty of perjury one of the following declarations:
n H p () 1 have and will maintain a certificate of consent to self -insure for workers'
K w compensation, -as provided for by, Section 3700�of the Labor Code, for the
D
J Q performance of"fie work for which this permit is issued.
Q O ( ) I have ab will maintain workers' compensation. insurance, as required by
U Q Section 3700 of the Labor Code, for the performance of the work for which this
L rn I— permit is Issued. M workers' compensation insurance carrier &;policy no. are:
z Carrier +.!'r3!'"L: b{ kdLl Policy No. lo}1�1�1.01.
(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,
1_ 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.
DA c %_, .rAPPlicant.__... _ '' ` ✓' ..a. ..�:.... .�
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 application 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.
• y
.Signature (Owner/Agent)kt'ti r'r• •�a�s,:.'"'' Date ! �;.}jam?.
✓ i :'
BUILDING. PLECRMYhIT PERMIT# :
M'0464
iYp�
DATE VALUATION Wa ,%e7se.�•r.-1,10 LOT., VTRACT
JOB SITE %WJX Vdpi' S VONA
APN 772•-47
ADDRESS
OWNER
CONTRACTOR / DESIGNER / EN (NEER
SMATROW. 001WOWkZapf
7-.564 (,,0 XI1 ir TATF,:[,i.[��SI�;,Mirm )37
'r 64.5. °o,�3�i'a"Rycy,T�"r�mr4-.C�;=�� r 155 ,
r". �2"L9'!:#cX1Va�31�r���a
F;°i:2^1,(=3
USE OF PERMIT
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WA.IaZSPA. Old NTUVOWAY APPA )1,04, RMIXT.TaN TO PUN
€:E1F,�(:'I,: i� 't�U'£� 7'Ca �3LL:1'Il`'L� 1�y�`U.;i2�If.E� L�Ii' S�:S�lF, i''L,a�N `f"�"1'P: •
C �4 4t�`�t S�lC`•r11 `4;iftY 4f,16 sV
MMM) ED CCAFFM OF t:;`L?TV
17 .` o
CUNta' UICTIC!H;:EE 103 -WO -438.000 slrmso
PL.AN CHEIrK VXH it. �13�33£s
WiRCHAWICA1, T'f's{= . 1 Cr1 AfI R� kl �C i} i 9 i.wi1
1✓LEC'd'l�IfI-Al.}%
1$16100
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AU 114 PUBLIC PLAC015-REW 270-D10-445-000 SIM..'7`9
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RECEIPT
DATEr� ��BY
- r°
DAj@ FINA INS CT
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Slab Grade
Ducts
Return Air
Steel
Combustion Air
Roof Deck✓
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.6
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wail Firewall 1
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROV LS
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
PLUMBINGP VALS
Gas Test
Electric Final
Waste Lines11ti,
onlali_
Heater Final
Water Piping
�
Plumbing 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 F On
Utility Notice (Gas) Icr- 7�:a;
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures /
Main Service 100,
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
11 Lh 41W
Final
Utility Notice (Perm)
COMMENTS:
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