0010-020 (RPL)'LICENSED CONTRACTOR DECLARATION
I h6t-by affirm. ' under penalty of perjury that I am licensed under provisions of
Clog 9 (commencing with Section 7000) of Division 3 of the, Business and
Professionals Code, and my License isin full force and effect:
License # Lic: Class Exp. Date
W 0113112
V16 't Xu.
Date SiSignatu�e of Contract K= r:
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, Busirfess & Professionals
Code).
I am exempt under Section B&P.C*. for this reason'
Date Signature of Owner
WORKER'S COMPENSATION
ENSATION 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'
compensati6n, 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 &
. p6licy'rio. are;
Carrier Policy No.
WrATE FUND
(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 sDp-uld become
subject to the Workers' compensation provisioly; "Section 3700 of the Labor
Code, I shall f rthwith comply with
Dte: Applic6nt^ -A
Warning: Failure to secure Workers' Compensation coverage is unlawfu.1 and
shall subject an employer to criminal penalties and civil fines up to.$1 00,000, in
addition to the cost of compensation, damages as provid6d,for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Builclino•and,Safet
y
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, A'Ishall, indemnify
& hold -harmless the City of La buinta, 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 en ' ter upon
the above-mentioned property for ihspbction pbrposes.
Ai6nafure. (Owner/Agent)' baie\'
BUILDING PERMIT PERMIT#
DATE t VALUATION LOT TRACT
JOB SITE' r APN
ADDRESS
OWNER CONTRACTOR DESIGNER EN (NEER
I
(11 QIrlsyl: HOMES MAL ITAMPT011 &a VAZATRAT POOLS
22fJo vmmbw cm= 'gun, I 50 9-522 D014JUDS014 F01
MRS79A CA. 91720 LUCERKEVALLEY CA, 91356
(760)248.60 -IS C.M.4f 4335.
USE OF PERMIT
POOL 10TWORIOPA
POOL & SPA QN1 LY-ALARAMBARRJERS SHALL 8? IN PLACE AT PRZ
Pl"rliift MSP.F.CT10KM)L 1QUIPMRNTIMCWBURE 13 NOTINCLUD96
M THIS I)EMMIT
POOL ANVOR SPA. '4,000,00 L,8
A=AA=C0ff0FC0J1;91RUC_f10X-
.
PERWMICK WMMARY I . ..
.PIAN CHECK Fey, 101.000-139,4418 S10.30
CONSTPLUCTION ME 101 -00!418 -WO $162.00
b AWKORCAL M# -- POOL 10,000A.21-000 $24.00
1OLFCTRICAL FEE - POOL. 101 rc*0_4214?-000 $43,00
PLITMUM FRY11 Pool, 30T.a-G(M419-15110 $27,0
?Vlo
UJ
Z4
KW -TOTAL COMMUM10.9 PND PLAN C.HECX'
fiilllo
MW PRE PAW FSS
$0,D0,
RECEIPT
DATEBY,
J
DATE FINALED
INSPECTOR
INSPECTION RECORD
V,' 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 Pans
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
p
Set Backs
Electric Bond
Footings.
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
_
Underground Plbg. Test
Final
Gas Piping
l�/8
_
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)