0204-196 (AR)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
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
734094 RIS IAC 3/3.11l?31
.. iiia•:'
�ra=
Date Signature of Conttractor
OWNER -BUILDER DECLARATION`
I hereby affirm under penalty of perjury that I am exempt from the Contra`ctor'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).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
( ) I am exempt under Section B&P.C. for this reason
Date . Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury 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.
( ) I have and will maintain workers' compensation insurance, as required by
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:
Cartier:., ZUR1C!H A. AZRJCAN Policy No. W0322096:03
(This section need not be'' completed if the permit valuation is for $100.00 or less).
() I certify that In the performance of the work.for which this permit is issued,
I 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 the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith com ly.w, ith those pr vise nss,-,_�-�1
Dater -•f "t��- Appli ant
Warning: Failure to secure Workers' Compensationco a age 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,perform'e. under or pursuant to
any permit issued as a result of this appllcatoniag•rees to, & shall, indemnify
& hold harmless the City of.La;.Quinfa,.ficers, agents and employees.
2. Any permit issued as a result'of thls,appitsr.ofllcafiori. becomes null and void if
Y*; P. L:
work is not commenced {`within_ t 1,80 'days'; frorh date of issuance of such
permit, or cessation of ;work for 180 days .will subject permit to cancellation.
I certify that I have'read; tt iggppl'ication and state that the above information is
correct. I agree�:to comply'wdh aII City, and State laws relating to the building
construction;` and:hereby;•authorize representatives of this City to enter. upon
the above mentioned property for inspection purposes.
Signature (Ow -A/ �� "�*�- Date-., I `
BUILDING PERMIT PERMIT#
»,
DATE VALUATION LOT TRACT
26960
JOB SITE
ADDRESS
APN " •' `
OWNER
CONTRACTOR /DESIGNER /ENGINEER
CENii Ey1-10MES
pMO1:01C HOMES
22543 �i'•.1:35'DLOW ACLS.', SI'f7ITCP 150
2250 WAaRDLOW CIMIMw A 501TE 3.50
C"ORONA. CA. 01720
C.OR0NA `7 fiCA 91720
(149).79.4000 (7214 5761
USE OF PERMIT
�L WWIT 1 ArMMOM
,ADDITION t;}'M 263 SX MINI SU Z T 0 I,OT17 WHIL Ze U.14 VER : z
CONSTRUCTION, PWI 4%
CUSTOM 0OMTRUCTION 263,0111 OF
7�' e IJVIATED C°t.ST OV %O1ik"I R*U( nO.'It
PZ03SM ' FEE 9101AMARY
CONSTRUCTION FEB 101.000«4153 000
PLAN CriWX FEE $39-53
ELECTRICAL EEE �, ?� 4000.4.20.000 $14,93
STItUfiICAAdi3iflC9'L5NELF: Y` IIJ DC)1 nor"4�-00tk - X3.53
ART W PU13.6C I') M REW 270.000445.000
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CITYOFIAQUIGITA
FINANCEDEPT.
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RECEIPT
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DATE �' "
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BY (�
DATE FINALED
vel
INSPECTOR
4 �,a4!r^�1—�
0
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 8 Controls
Party Wail Insulation
Condensate Lines
Party Wail Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
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: