0108-346 (BLDG)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
Professiona Is Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
Date signature.6i
OWN ER'BW|LDERDECLARAAON
/ hereby affirm unuo ,penalty of perjury that |amexempt from the Contractor's
License Law for thehd
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 & Professich als Code). ..
^ .. ~,/~. ~. ... property,...
~~`~', co, —~.~.° .. .. .._...d
von��o� m constructm�pm|m�(Geu. rmw. Business & pmfeaaiono|v
Code)�
() | am, exempt under Section
B&PC.uvthis mavoh�____�___
oam Signature -of Owner ^
WORKER'S COMPENSATION
I hereby affirm under penalty of perjury one of the following declarations:
I have and will rrfaintain a certificate of consent to self -insure for workers'
oomppn$adon...as pm,moo for by Section 3700ofmetauo CoUa. for the
performance of the work for which this -permit is issued.
'I have "and will mainiain wor,kers' compensation in ed by
Seciion.3700'bf the Labo�.666e, for".the:'Oerfoemance of the work. I for Which this
permit is issued. workers' comp6nsaiio'n'insurance carrier..&. policy 'no. are:
Carrier
Policy No.
(This section need not- be completed if the"permit.-valuation -is ilor $100.'00 or less).
'that in the performahce' of ihe wor'k'fg'r which . this permit Js issu6cl-
I shall not employ any person in any mann.e'r so as to _ me -subject to the
work - ers' compensation laws of California,. and agree ihat if I should become'
su6j'ebt'to the work§rs' compensation . provisions 6f Section 3700 of the Labor
Code, I shall forthwith cbrfiplywith those provisions.
Date: Appli6a'
Warning: F ' ailu�e to secure Workers' Compensation coverage is unlawful'and.'
shall subject an employer to criminal penalties and civil fines up to $1 , 00,000, in
addition to the cost of. compensatio ' n, damages as. provided for in.Sectioh 3706
of the Labor Code, interest and attorn'dy"s fees.
IMPORTANT is'hereuvnmade to the 'aind
for o ponnh subject to the conditions and restrictions set forth on hio
application. `
1.Each person upon whose behalf this application is made & each person. at
whose request and for whose benefit work |operformed under o,pursuant m
any ponnn issued as result 'dthis appocamn agrees to, & ohuo. indemnify
& hold harmless the City oxLaQuinty. its officers, agents and employees.
2. Any punni\ issued as o result ofthis application becomes null and void if
work is not commenced within 180 ua»o from date of issuance n/ such
ponnh. o,cessation orwork for 18odays will subject permit mcancellation.
|oertify that | have read this application and state that the above information io
uuneo. | agree mcomply with an Qty, and State laws relating to the building
uonmmnnon, and hereby authorize representatives oxthis City menter upon
the above-mentioned property for inspection purposes.
'
Signature (Owner/Agent)' Date
PERMIT #
BUILDING PERMIT
DATE VALUATION LOT 1.11 ()P -346 TRACT
JOB SITE
APN
ADDRESS
AVE, 0302
USE OF PERMIT
40d 14 0"AlIV9
CITY OF LA QL1iNTA
FINANCE DEPT.
RECEIPT
DATE
BY
DATE FINALED
IN OR
INSPECTION RECORD
OPERATION _ DPA i E �-
INSPECTOR OPERATION
DATE INSPECTOR
3UiLDING APPROVALS
MEC-HANICAL APPROVALS
r Set Sachs;t--wr,der4rcuad
Ducts j
---------__ _•.._ . - .__-._..
Du:;,E3 —
Slab Grade-- -- +
- --� ReturnA r t
Steel (
Tbusticn Air
F -Cc' Cact:-i
cxf,aust ars
-
---�-� Compressor ( i
Ir)SL;13tlOn --- -
! Fireotace P L —�J-
I F`reulac.3 T.O. — ^ — _ --
Ven! t I I
-?'ns & Controls ,
Pa.ty Wail tnsuiat;o_n_-
�_ary UVall Firevrd,•t ---- _.. _-_. —_____ _-y .---__---
r EXIef!Or L301
.densate Lines
t
POOLPLC
S - SPAS
t =•r: -i
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Fitt>i
'.lG:!t- Notice
I ,ELEC i Rit✓aL APPROVALS I
Temo. Pcwer Pcfe
UnGercround Ccndud ! !
R:ugn Wiring ;
a
LCw Vo!tace Vlhnnz ( 1
Fixtures
I ( (
Main Ser.ice
i Suo =aneis
I
! :,.tenor Recectacies
Simoxe GetectCrs j
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,Final
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"'axle "wes--
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Enclosure
for !=imsn plaster -
WtoMl
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Fitt>i
'.lG:!t- Notice
I ,ELEC i Rit✓aL APPROVALS I
Temo. Pcwer Pcfe
UnGercround Ccndud ! !
R:ugn Wiring ;
a
LCw Vo!tace Vlhnnz ( 1
Fixtures
I ( (
Main Ser.ice
i Suo =aneis
I
! :,.tenor Recectacies
Simoxe GetectCrs j
-zm:) Use of Power t 1 I
,Final
! "titi:y NU*;Ce t P
r,.0M r1PNriS:
av 3 J6 -00
3 -197 - oa
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Page of ,2a... _..
DAVE STEAVLLENS
InS- P&tion`Servic'es
PROJECT C,,& A W F--57 'PROJECT N'.. c� w ci 2 - O 3
ADDRESS` S"y -q / _,)LI, 2-j 7 .off. CLIENT�f��-1 o A .
�A11 �i LL PLA09R'IJ& t 3 .:.- DATE . c2l M f-\(t.CAA ala o Z
BLDG. PERMIT # ARCHITECT 6.04-41A. A 2cv{ .
ENGINEER c7 A J:y; 6 z,,�cr.. CONTRACTOR' .'� CL . w) A,vL r . c_A I=, L
INSPECTION TYPE
INSPECTION REPORT
Y
CERTIFICATION OF COMPLIANCE To the best of our knowledge, all of the.reported work, unless otherwise noted,
—substantially complies with approved plans, specifications and:apphcable sections of the builder g codes. This report covers
?the locations of the work inspected only,'and does:riot constitute:eng nee i .opinion or project:control.
CERT. NO. '� S` T 3 INSPECTOR NAME :A J:.A CA -,is
DATE -C:>77 i� IMC 4 UO Z INSPECTOR SIGNATURE N
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Page a1 of o2,
DAVE STEAVENNS;
��,TA(�S - 1. �.3.I 5..: g ��oc►`c:,�L A 14 3S S - Cor•.'7LtT
CERTIFICATION •OF.COMPLIANCE To.the best of our,knowledge'-all of.the,reported work; unless otherwise noted,`
^� substantially complies with approved plari"s; 'specifications ana a pplicablesect(ons of the building codes.This report covers
;the locations of the work inspected only.and does not constitute engineering' opinion or,project conteol.
CERT.NO. ®�S/ -37�- �d INSPECTOR
.NAME ��A�JE SfGf1 ✓£,tiIS
.S,t �` Ad
j (Print Clearly)
DATE (o m W 2 C W o200 L INSPECTOR SIGNATURE` A✓ C ,
.;;�: ^Wasw;y�,jM
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SY -� 4D A ti r4.1 L �,!✓ � 3 q
--- - DAVE
Page �"
STEAVENS : t
of
Inspection Services
229
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PROJECTI'G
PROJECT.-# o:v2 - O
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0
BLDG.. PERMIT #
,ENGINEER,
..'INSPECTION TYPE
3
CLIENT A w. ES i Ho R
DATE .:� S 2G�-F 000 Z
ARCHITECT CDL 6A A R C4
.. CONTRACTOR b ICL f'� A 2 PA C.I,
`'
--INSPECTION REPORT
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ty 16
t3�oc�`� It - S13A2 NA1��J(, LLWE2;
CERTIFICATION OF COMPLIANCE To'tte best bf our knowledge;.all of the reported work, unless otherwise noted,
^,substantially complies with approved plans; specfications and appllcable.secfions of the building codes. This report covers
,.;the locations of the work inspected only and does.not constitute engineering opinion or project control.
CERT. NO. INSPECTOR NAME
DATE INSPECTOR SIGNATURE ' Y`: iia'
. .. . .. :7+ +isy.. .. .w^ • .o �: T,., �,y�. W'�cCi�ct.'�!'r-.!f.�':::.sS ww;..�.�` rt4..�•!!�� �. .:y ..i'!1•>.�aa.:gc•:. Y'•,,.N-_-j�
Page _L of i
DAVE TA NS
R
Inspection Services
,:'PROJECT.aK, PROJECT # ' r avo 2 - p.z
ADDRESS CLIENT
DATE ' . S.M;�q �2 C r-1. ^
o� o d Z
BLDG. PERMIT # ARCHITECT :Go
ENGINEEil ,, A) SAJa t CONTRACTOR b r- L : rY► f1 "iZ t4\
INSPECTION TYPE
INSPECTION REPORT
L)X IL k _ A� PAS
.ObnnLr i N
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JCkor2 ,u.i 5-/��NrErJ
CERTIFICATION OF COMPLIANCE To the best of.our knowledge; all of the reported: work, unless otherwise noted, -_
-�, substantially complies, -With approved plans, specifications and applicable sections of -the building codes, This report covers '
i
the locations of the work inspected :only and.does not constitute:engineenng•:opmlon or project control.
CERT NO. O� S / �� 5 Q `INSPECTOR NAME .54
.. c •.: -,fix `. ., __
DATEA;' I� l4 e C!^l c Oa L INSPECTOR SIGNATURE- . • `PTS!