9911-054 (BLCK)`
' LICENSED CONTRACTOR DECLARATION
^I he'roUy affirm under penalt.2�'of perjury that I am licensed under provisions of
Chapter 9 (commencing v4ih Section 7000) of Division 3 of the Business and
Professionals Code, anairm'y"License is in full force and effect.
License # Lic.bla�s Exp. Date
Date Signature of Contra`Ct�'or_,,,,
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
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 & Professionals Code).
1; as owner of the property, am ex ' clusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
I(-) I am exempt under Section B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION '
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I h ereby affirm under penalty ofperjury one nfthe following declarations:
()| have and will maintain acertificate ofconsent mself-insure for workers'
onmponoation, as provided for by Section 3700 of the Labor Code, for the
performance cfthe Work for which this pe,mi,ioissued.
( ) | have and will maintain workers' compensation insurance, ovrequired by
Section 3M0 of the Labor Cocle, for the p6rform'ance of the work for which this
permit is issued. My workers' compensation insurance carrier & policy no.. are:
Carrier Policy No.'
ST ATH FU AM 11280990-9-1)
(This section need nm1ecompleted ifthe permit valuation is for $100.00mless).
( ) | certify that inthe performance ofthe work for which this permit is issued,
| shall not employ any person, in any mannerxoaouuuaoomosubject mthe
workers' compensation laws of 6aliforniafand agree that if I should become
subject to the workers' compensition provisio6s,of Section 370d. of the Labor
Da Applicant- -
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the c ' ost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application i»hereby made tothe Director o/Building and Safety
for o permit subject to the conditions and mot,ioVonu set forth on his
application.
1.Each person upon whose behalf this application iomade meach person au
whose request and for whose benefit work 10performed under or -pursuant m
any permit issued aoaresult o/this oppUcomnagrees to, & shall, indemnify
& xo|u harmless the City o, u* Ouinta, its o#ioom, agents, and employees.
o. Any permit ioauod as mauxofmio application becomes nv|| and void i/
work is not commenced within 180 uoyo from date o, ioxuonno o/ ouox
ponnit, or cessation ofwork for 180 uuyo will subject permit to cancellation.
| certify that | have read this application and state that the above information io
correct. | agree mcomply with an City, and State laws relating mthe building
oonmnuction, and hereby authorize epmoentah"oo of this City to enter upon
the above-mentioned property for inspection
Signature (owner/Agent) /
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BUILDING PERMIT
DATE 11foq
LOT TRACT
JOB SITE APN
OWNER CONTRACTOR DESIGNER ENGINEER
"ACT R
(76(1)q67-0069 CBL# 3955
USE OF PERMIT
Q��8�1,8iALDNG
64LJF~0H)QAQ[EN}IALL-CITY STANDARD
5 FT. WALL 460.40 LF
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PERMITD�Ck, SUMMARY
V&-, 101-008~418-000 S_Ito$
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PLAN C'.HF'CK SJ100
'Wr48VERTW8T Y@E@O0P, NOW I 83.1.0f)
BY
oATEnw^LEo |wopsoron
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
['. Deck
Exhaust Fans
.*O.K to Wrap
>.:.;
F.A.U.
Framing
Compressor
Insulation
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
57-
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
57-
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
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
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: