RPL (9908-164)_ LICENSED CONTRACTOR DECLARATION
'If 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
$ dlw'7 t1 081.3111.
Date �f ,'Signature of Contra 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:
( )_ I, as owner of the property, or my -employees with wages as .thei .-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 exclusively contracting• with' licensed
contractors to construct the project (Se6.�7044, Business &:Professionals
.• .. '....- ; , ' �, r;
`O I am exempt under Section : B&PC: for this reason
Date . Vii! Signature of. Owner T
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty, ofperjury. 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.. "
"f ('have and will maintain workers' compensation insurance, as requiredty
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 Policy.No:
YaM• r.p: 1i d'2`+•+i1 .. ../f=nl /f(� P1t [aTaO`! a
•tioJ.I1l:;, 1aJ.i'tli,!' ,, 4•N.i^.J. ^V�kIf:F��!
(This section 'need- not, be completed if the permit valuation is for $100.00or•less).
O I certify that in the performance of the work for .which this permit* is, issued,
('.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 t workers' compensation provisions of Section"370Qof the Labor
Code; I fort +!Yth comply withthos.'� prowsionsr .
Date:. %r�Applicant
Y .
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, indemnify
& hold harmless the City of• La Quirita, 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 p"spection purposes.,
Signature (Owner/AgeR 4
1e� 'Date >/4
PERMIT #
BUILDING PERMIT.
DATE VALUATION - LOT TRACT +
JOB SITE �j(
ADDRESS c•6.91. .�."S �,l�a,�'�1V �,j�^1%j�/i�
APN
OWNER
CONTRACTOR / DESIGNER / ENGINEER
t r�^rr �Y a rr 5 a r�.er:� ".
S A.'..Y L7.4 7Y Y.I.AA !. .ld\,.ItV.0.fy4V
c�•r;try V�nr�Ccyt, ^aa=. -ODT rf-T -mq
-WAL V 1:,. IiiJ iib l'! \.A.l �li71.I1,Ja! l 1.2
71,61 R'yM1ta'14A AVE . : .. '. , '
73011 <.EOT::ft IRY Ubt DR., sUTFE r•4
RIVERSIDE CA Q104
PAJLM DE5,ERT CA.- %1160
t l6f1)�d t -4d)12 CRTA#I 1044 .
USE OF PERMIT
100L UoA CMIt' - .Ji AiWSr31g11U,,19 SHAi.Z.OL I 6?Lik i ,O `F .
,rraN.
FOL MNDvF.l..ST-A 46.4010.00.LS
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]..:M•,,, 0.. •l,.a Y<,11.n. +Ct. i.!W.i,SL�IY -
.. N�: NJI,fd Illi
IAtlPj`}1lylY.v F
PLAN CRY 1 a� i01-000 —a3�a:a�
V-160, 0-4:Y8•00
14:[f::C�%�Y� �C:�1, f'�FW ,•� 1''t?>.k8.: - � L 5..-'�)'tJkdt'� 1 •f)f1L - � • .3• �9 .flt
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of
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sui4-vim, i^oT+Ivw fC, t VON �X,i40 P; ,AN CJ -11 ECK.
5xz125
< U"SS x3 ' ,I'tACD .iaEE5
4 ..
�. $0.00
_.
RECEIPT
DATE
BV `1I
DATE FINALED
INSPECTOR
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
F.A.U.
Framing
Compressor
Insulation
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
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I I
I 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
COMMENTS:
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)