BLDG (0010-209)---_'_
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
Pfof6ssionals Code, and my License is in fullJorce and effect.
LicenseA., Lic. Class Exp., Date._
77701 C53
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 exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
I am exempt under Section B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
| hereby affirm under penalty of perjury one o/ the following goolasUomz
()| have and will maintain acertificate ofconsent mself-insure for wuma��
oompansation, as provided forby Section 8700 of the Labor'Cudn, for the
performance o,the work for which this permit is issued.
| have and will maintain wmdmo/compensation insurance, as required by
S0 i0n 3700'of the Labor Code, for the do oo,oxtxo work for which this
permit is issued. My workers' oompopa�ion inuumnuaoanio,& policy no. are:
Carrier Policy No.
� 0YMAWTION ONAIA '
. `
(This section need not be completed if the permit valuation is for s100.00mless).
( ) | certify that inthe performance ofthe work for which this permit ioissued,
| o»an not employ any person in any manner so as to u000mo subject tomo
workers'' compensation laws o/Caofomia. and agmomaxi/,| should become
' isubject,6m k ' compensation provisionsof Section 37Ooo/the Labor
C�e, 1,,,s all, forthwith comply with-tho provig-ionsr'
(9 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 cost of compensation, damages as provided for in Section 3706
o/the Labor Code, interest and attorney's fees.
IMPORTANT Application iahereby made mthe Director ovBuilding and,aafety
for u permit subject to the conditions and mm,ioUono set forth on his
itpp|iocoion.
1.Each person upon whose behalf this application iomade ueach person ou
whose request and for whose benefit work ioperformed under o,pursuant m
any permit issued aooresult orthis uppnvoxonagrees to, ushall, indemnify
�
4 hold harmless the City of Lo ouinta, its officers, agents and omp|oyeoa`
u.Any permit issued aauresult o/this application becomes null and yvoid if
work is not commenced within 180 days ,m date o, ioovannv of'such
pennit, or cessation cdwork for 180 days will subject permit to cancellation.
� |oortify that | have read this p !iCation and state that tha'uboveinformation is
� oo,nem�|agmomcomply with'aU`Cit�and State laws m|oxinQoothe building
� City toenter upon
top
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� b nature V]wnonwge o
r
BUILDING PERMIT PERMIT #
DATE VALUATION LOT TRACT
Ananny: &12A. 75
JOB SITE
.ADDRESS 'JAPN
OWNER
PT -M;% rA7JLAJTAWK193�
49-580 NDMIDN DR
1A QwWrA,
USE OF PERMIT
CA 922.53
CONTRACTOR / DESIGNER /
70-1 Go *nwSpa, wwf�D 03
fMYHOMMAM CA 922710
C160)331.0860 C&LO 3735
`
PWI, EQUXPM10IT83VrU)SURK.^35L.KJ[fWALL ^CDY'SIAINDARD i
'15100 LF
Es7OQ"mCOST aw comsmadoN 324,75
FQ3ME0KE S (MMARY
MNSTRUCTM F1119 01 -000-41 V-000
,
CON&TRUCTION AND PLAN MECK, MV"
L -PRF
RECEIPT DATE BY -'I 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 I
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
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: