0206-072 (BLDG)iI hereby affirm under ,,penalty of perjury that a4:3 -m licensed under provisions of
P �. ;iChapter 9'(commencing with Section 7000),of;Division 3 of tfie Buslness and
CNI. UJ-' Professionals Code, and my License is iri full force and effect. i ;'; •;_
* ::, r r..
-.p License # ,f. , zt r`. U,
v Class Date f. _
In
IX
s Z ,� ate ~ �"Slgnature ofContracto
f `.OWNER -BUILDER DECLARATION ? 4e
H aW 1 hereby affirm under penaltyof perjury that f am exempt from the Contractor's
. CL License Law for.the'following reason +, '; 7
Z ( ) I, `as own4,o ,theyroperty, 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 & P ofessionals`Code.
�' ( )„I,"'as. owner oftheiproperty, am exclusively contracting with licensed
contractors .to construct the project (Sk'j7044, - Business & Professionals
`Code) r',
s
( )t l'am exempt under Se ',' _ ,' B&P.C'for this reason 2
O N , ,Date t tnt _ i Sigriaturet of Owner p
”' t
, ¢f{ ; WORKER'S COMPENSATION DECLARATION
v 11 Z r a r f. r. t
o `� )I `hereby affirm undery penalty of pery'ury- one. of the following declarations:
H 0 0 (J)t i have and w111 maintain a certificate of.cnsent to self -insure for workers'
X W!u- , ',compensation„ es -provided for•by Section`3700.6f the Labor Code, for the
O, J;Q performance of the work for'which this permit is issued. _
co Q l�� 1,have and wlll maintain workers' compensation Insurance, as required by
O U `S&I vn 3700'of,the Uibor,Code; for the performance of the'work for which this
a rn }permit is Issued. rMy workers', �mpensation�Insurance carrier& policy°no. are:
— , Ca► * I.XI AON-INz3."'CS► t ` �; : i Policy No. WC3I20>41�5
CO
• dF'. "I . 1+'f . t u ,, tY'a'•a{ <` i .1.'
gv (This section need not be completed. If the permit valuation is for $100.00 or less).
etj );I certifythat in the performance of the work.for which this permit is issued,
'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
V subject to the workers';compensation provisions of Section 3700 of the Labor
Code, I;ahal forthwith comply with thos
ate: A v�� ApplicantE�
. ,y( '• Warningc 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
•, 0<4. of the Labor Code, interest and attorney's fees..
~tIMPORT
ANT .Application is hereby made to'the Director of Building andSafety
qt` ;forapermit,'subject to -the Conditions and -restrictions set forth on his
)application..1. Each personupon whose behalf thisapplication•is made & each person at t
�! whose request and for whose benefit work is performed under or pursuant to
any permit Issued as a result of this applicaton agrees to, & shall, indemnify
• •.: & hold harmless the,Cityof La_Ouinta, its officers, agents and employees.
J2.�Any,permit issued as a resuk'of this application becomes null and void if
o,'' -work is not commenced within.,
days from date of Issuance of such
. permit, or cessation of work for 180 days'will subject permit to cancellation.
±'8 t�Il certify that I have read this appiication and state that the above information is
'• i ':.,correct. I agree to comply with, all City, and State, laws relating to the building
�. i construction, and,hereby'authodie representatives of this City to enter upon
t the'above-mentioned property for, Inspection purposes. r ;
x' �ignature (Owner)Agent) � Date `--
- , t, rv- ZUILUIIVI,i�FLKml.l . I.�r < �/^����������^)y"/y
f I ' k �P4 ��yi
DATE{ G �i .e : VAWATION LOT �� a ' CTRpAriTtq�#pM►}� f
i
JOB SITE
gDO
ADDRESS
DD REss . 3 4
•; a-
OWNER.
CONTRACTOR / DESIGNER / ENGINEER - . i;'r rYi� :
..
POA V=r R� At. HOM#��UWw rr 3
I luftri.Yi-I►Alt�fi if CK1R n ' �
h
LA QUJ1M GA W233
SAW DIM CA' 92122
`
(f358)335•]47S - 5023,
T'
•.
USE OF PERMIT'
c�►xr z3LiII.D%wC�
SEISMIC RETRC6FIT; OIL= 3: 54-583,34-399,34-5m%
4
-54-001,134-M 54-613, 54-619,54-625, ,
VALUATION t30 000.0 �
COST 01!' GONSTI�C M7:C11`i
+`
yyam�' �y�w��..��v.•�, SUMMARY
Fi0,RM d .DER SUQ2�I,t RY
�•
CONSTRUCTION FILE 101.O10KMI R<O00 - $439.50
STRONG MOTION FEE -12E 11) 101-000.241-000 $6.00
Em -core. CON urrtOX Arrl PIAN c3nW�
; S40. 50
Lr%l PRE -PAID FM -
'A
Teti. I MUT MY S DW. NOW
AUG 212002
CITYOFIAQUINTA
rK
FINANCE DEPT.
fiECEIPT
DAYE d
• r�.�.
@y 5
:W.:41 1. � .
DA NA D
j� s r�
INSPEC
I
INSPECTION RECORD
OPERATION` -
DATE"
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs _ -
UndeMmund Duds
Forms &Footings,
Duds ,
Slab Grade
Return Air -
Steel -
Combustion Air - _
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Compress"
Irmulation
Vents +_
Replace P.L
Grills
Fireplace T.O.
Fans & Controls
Party Walt Insulation -
Condenade Lines
Party Wall Fwewall
Exterior Lath - Q
Drywall - Int Lath
14
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel .
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground PI . Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Unes
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Laterdl
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Conduit
Rough Wiri
RoughWiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Racoptacles
G.F.I.
Smoke Detectors
Temp. Use a! Power
Final
Utility Notica (Perm)
COMMENTS:
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