0201-062 (BLDG)'i'f'�.vt..•t �... �.... `... .... , .. .. ....:.t,;kt-"x,MI.T R "_. " ' ,..,:.�
rJ
Phereby affirm under penalty of perjury'ihiit l a6 licensed -under provisions'of 3 `BUILDING. PERMIT �'
r Tt CUo
ha ter 9 commencin with Section •7000 of Division, 3 of the. Business and `3 c. ; ' z
N P ( g ) .. DATE ls; > ` VALUATION ;S r LOT , {� Etii-�►6+�iZ TRACT
N Professionals Code, and my License Is In full force and effect. `
p Ucense # + 1c. Class Exp. Date
CCY5 JOB SITE ` ' p. a' a ' ('' i' ' . APN
W r :. 7 31, 2, ,, T B 0 ADDRESS -7,1ROM URACS � 5 ` f �i � ,
•d' Z Date SignatUfe Of ContfaCtOr OWNER - CONTRACTOR / DESIGNER! EN INEER
~ `O• '' OWNER -BUILDER DECLARATION FCS► gVI T` 3113 1:iA . A1g$4 CDN . Y3I:'.I: MM PAMC G�.
COMAMR 3. i
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's PQ BOX 106{) 1333 30CT171 CO= W.0,11WAY M M
~ U) License Law for the followingreason:
Z - O. I, as owner of the property, or my employees with wages as their sole 1�AQ�A CA. 4233 G�A3YTFLX..A. Cil 9�di07
compensation; will do the work,'and the structure Is not Intended or offered for5$23
sale (Sec. 7044, Business & Professionals Code). USE OF PERMIT
I, as owner of;the property, am exclusively contracting with licensed
contractors to construct the project * (Sec. 7044, Business & Professionals MXS�[ iL�11AYi5 t' t . `
t
�4 ()�I am exert pt uniler~Section t B&PC'for this•reason ' - FfUILDIND 1d, Otf•9 81; 3 , I *360 VCyL1i?J�'AIL`��
�. fiDate i t Signature'of:Owner 3Tftlt TU M, A+ lOYlIRC.ATIONS
a.Q �'`.' WORKER'S COMPENSATION DECLARATION �j'
a Z �., i '
C:) �, I hereby affirm under penalty of peryury'one of,the following declarations:. I ,
H p` '(•)r,1 have and will maintain a certificate'of consent to self -insure for workers' VAIMATION �gOG0.U0 L5' G� �A� 1 � �
X'W �'; compensation, as provided for by Section 3700 of ,the Labor Code; for the f3
�
. J • Q "pert rmance of the work for which this permit is issued.
Q I. have and will maintain workers' compensation insurance CB as required by YO LAQWINTA
p' IU Q•.: Sebtlon 3700 of the Labor Code, for the,performance of the work for which this
4. permit 1s Issued. My workers compensation insurance carrier .& policy no. are:`
Center:'Policy No.
aD 5 41'x, TF'. l*V' ` OWIUNiTfl 0415 - M M!!'1 D CM OF C011181 2%MAD
`
(This section need not,be completed If the permit valuation is for $100.00 or less). '
O I certify that in the performance of the .work for which this permit is issued,twUNO'i,RUGTiom M" 101.000.41 "go 8'107.00
' I shall not employ any person in any manner so as to become subject to the STRONGA40 '1014 I - RES1.0 10.1.WOQ 24.1, -NO
' c workers' Compensation laws of. California, ,and agree that if I should become '
'subject to the workers' Compensation provisions of Section 3700 of the Labor
`I {. Code, I s all fo withh comply with those�rpvisions.
( + `Date:
�rr, : Applicant y M
Warning: Failure to secure Workb,rs 'Compensation coverage is unlawful and, ' • + ' ay,
shall subject an employer to criminal penalties and civil fines up to $100,000, in +
addlilon to the cost of:cbmpensation; damages as pr6ided.f6r.in Section 3706. "
Y r =of the Labor Code, interest acid attomey,'s fees.
r IMPORTANT -Application is hereby made to the Director of Building and Safety
'
or :`a- permit subject' to ,the' conditions' and,, restrictions , set forth on his
Kaplilication.
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 $'[iB- '�I. C01MUCMX ANUG PIaiti~1' CIS • ,. $20.00
any permit issuedas a result of•this applicators agrees to, & shall,: indemnify `, .. UmP'AU.PAIpFM + p.00
* ° '&_ hold harmias5• the- City of La .Qulnta, Its officers, agents .and employees.
2 Any permlt-Iisued as a result -of this application becomes null and void, if ? '
N,'., Fwork snot commenced within 180 days, from date of Issuance. of such, TMP=Mf r= DON
p�rmft, or.6essation of work, for 180 days will subject permit to cancellation:
r I`oertify that I have read this application, and state that the, above Information is -
.. , .
-F "correct. I agree to'comply with ail, City, and State' laws, relating to the building.
`-constructlon; and herebyauthorize-representatives of'this sty to enter
the above mentioned property for ins ection py'rposes
c r ARECEIPT DATEI BY ^SPECTOR
} ` Signature (Owner/Agent) 1 ` Date' C1
I _ t
I
`POOLS - SPAS
BLOCKWALL APPROVALS
Set Backs i I 1 Electric Band
sono tsearrt AWoval to Cover
Equipment location
Undermredmd F ark -
Uncloground Pibg. Test
Final
Gas P
PLUMBING APPROVALS
T
Ekcht Final
Waste Lines
Heater Final
rzI�VSPECTION
RECORD
Plumbfng Top Out
Equipment Enclosure
,
O.K for Finish Plaster
Sewer Lateral
Pod Cover
4'rti.
Encapsulation
Gas Piping
OPERATION
DATES;
.INSPECTOR .
:' OPERATION
} :;
DATE
INSPECTOR t
COMMENTS:
Sl�sl�Z
r a
Final
Utility Notice (Gas)
ELECTRICAL APPROVALSu-
Temp. Power Pok
Underground Conduit
Rough Wiring
BUILDING APPROVALS
MECHANICAL APPROVALS {
f1Aa _ xvice
sec eaao:
u Duds
_
Smoke Detectors
Forms & Foollryh
pueb
�s�
Fhul
Slab Grade
Retam Air 77,
steel a -
combustion Air
Roof Deck X
Y_,.
Extwet Fana
O.K to W -� : .z
FA.U.
Compressor
ttnuPatiom�
Vents
-
;'..Fkaplace
P.L.
Grtafe S'
4
gFkapims
T.O." e -0 v ;; , lfy.
Corkrols
.;.
VM InsullftR. :y,
-
CCnrlensaie urleS
w
i
Wall Firewall
Exterior lath -:
aLob
If
I
`POOLS - SPAS
BLOCKWALL APPROVALS
Set Backs i I 1 Electric Band
sono tsearrt AWoval to Cover
Equipment location
Undermredmd F ark -
Uncloground Pibg. Test
Final
Gas P
PLUMBING APPROVALS
Gas Test
Ekcht Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbfng Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Pod Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Sl�sl�Z
r a
Final
Utility Notice (Gas)
ELECTRICAL APPROVALSu-
Temp. Power Pok
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdu-m
f1Aa _ xvice
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Fhul
Utility Notice (Perm)
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wPROJEC'I'� t : t -OT ... t. ..��a 6� � :P _ JECf ;#:
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t` ADDRESS • • ;, G IENT UJr-'-ST. ►,� OF �.� Lam-
;'DATE rAq c Z. ` E
' 3BbjG..PERNM. # � r \ARCHITECT_ : X.z3 t} •
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ENGINES !Y CONTRACTOR fi fi r� I 4`4,
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Re.�.:�i.� �citt av
INSPECTION TYPE
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► CERTIFiCAT!oh oF'COMPLIANCE To thea best of'our, knowledge;•allof the r'eported work,:unless otherwise noted,:
substantially coplrovect'plansspecrfications and'applicable sections of,the bwlding,codes This;report.covers f,
t',ti:f�catieet thus ` sated only and`does:not constitute engineering opinion or project control.;
~ � (
�•t4�.1 r - fr _;,
f` .
=sCERT, O.INSPECTOR NAMEr�i~
"\ G��J` DATE t.qG 'r�
., INSPE_CTORSIGNATURu r �Si ` • ,
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.;,,�,-.CEFlTlFlCATl0N,`0F1 COMPLIANCE stofourknb�vledge� all ed.wdk, ubleit o"rwjjj0 jj6t
obOMPU
-isu stan allk,`boh__lIes*fth'appro dd,plans" 06cd"
V __ y tionsana applicable
. iood* N 's _s 6ftliiliuildir r
section idiodesThid
_eport
inspected ns o ft iaVJnlVipd'd64i�6j c6_6kft6ti.irgiiiiehfibj* oil Project
TIT NS
FIT. NO. iCA iA�O�
"%-,INSPECTOR NAME.
, - t, L S
T'^
DATE INSPECTOR SIIGNA-fUREaa�l
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