0107-254 (RPL)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
Perofession ils Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
6-5 61 128 1 Ar4l
OWNER -BUILDER DECLARATION
I hereby affirm under penalty ofperjury that'|omexempt from the Contractor's
License Law for the following reason:
( ) |, aoowner ofthe property, ormyemployees with wages aotheir sole
compensation, will dothe work, and the structure ionot intended oroffered for
sale (Soc.rn44.Business & Professionals Code). .
( > |, as owner of the. property, am exclusively contracting with |ioonoeu
contractors to' construct the project (Soc. 70*4. auoin000 & Professionals
Code). �
( ) | am exempt under Section . o&PC. for this reason
Date Signature o/Owner
VVOR�ER'�;COMPENSATION DECLAR�ON
O`
| hereby affirm under penalty of perjury one of the following declarations:
( ) | have and will maintain ocertificate o/consent mself-insure for workers'
compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permitioissued.
I have and will maintain workers' compensation insurance, as required by
,Xdctibn 3700 of the Labor Code, for the performance of the work for ' which this
perirnit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier ' Policy No.,
(This section need not be completed ifthe permit valuation isfor $1oO.00mless).
() |oemfy that in -the performance o/the work for which this permit ioissued,
| shall not employ any person inany .manner u000mbecome subject mthe
workers' compensation |owo of California, and agree that if should become
subject h k ' 6ompensationprovisions cdSection 3700 of the Labor
Code, I shall forthwith comply with th&e�proviSibns.
""= °pp""="
Warning: Failure to secure Workers' Compensatio verage is unlj12 _Ulne
i In
shall subject an employer to criminal penalties and civi fines up to $1 R�d
addition to the cost of compensation, damages as provided for in Sell 37 6
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building a Id Saf y
for a permit S,ubject to the conditions and restrictions set fort on
1. Each person upon whose behalf this application is made & each Lerso
whose request and for whose benefit work ioperformed under or.pumuamtn
any permit issued oaoresult nfthis appnoatonagrees to, ushall, indemnify
& hold harmless the City ofLoQuinta. its officers, agents and employees.
o. Any permit issued aoo result ofthis application becomes null ow8void if
wu,x is not commenced within 180' days from date of issuance of such
po,mit, or cessation ofwork for 180 days will subject permit ,ocancel axio�,.,
|certify that | have read this application and state that the above information io
correct. | agree tocomply with all City, and State laws relating tothe building
construction, and hereby n i 'of this City to enter upon
the above- menti oned property orinspection$urposes
Signature (Owner....
PERMIT #
BUILDING. PERMIT.
DATE VALUATION LOT 0107�24A TRACT
q
JOB SITE
7"90,RAHMO LA 9MINITA DUMP.
CA, 92253
PI -Ii -M DMIT"T CA 92260
(7650)340-9000 CBralf 355
USE OF PERMIT
1100), AiMOR. SPA 2100,00 L3
CGHM-3RUCT1011 VVE, 101-1000-11-18-000 VIM 60
H1XL'TPJCA1, FEE, - P0011, 101-000-47,0-000 $41(w
'101-000-419-000 127,00
L 2:::]
CITY OF LA 01JINTA
FINANCE DEPT
KIM-70TAL AND KAM (110'X
DATE
By
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
Bond Beam
Main Drain
Approval to CoverJ_G��l
Equipment Location
Underground Electric
Underground Plbg. Test
_
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Ile
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
2 /
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
_
FoQur_=
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)