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ii"A hereby affirm under penalty,of perjury that I'am licensed undei proVislons of
"Chapter 9 (commencing With.8edon 760):of Division 3 of the Business and,
Pioasslonals C&e, and rtiy b6iiiibls' 16 fu:li i6rce and effect
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LIc'ense # Up. Date
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'"'e",OWNER-BUILDER DECLARATIONj
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I hereby affirm 6fpedji� i4tlimexinpl from the Contractor s
`U6ens'6'Law f6r,ifief6iloivingreason '-,,r,,,f�,j,
i)` Ii is 6,Aihe�.bi the property; or my eimp'loye-'es with Wages as their sole
Comperisailon,—will do thb work,'andjhe stnIct 6re is not Intended or offered for
.'sale (Sec. 7044; business & Pr6fdssionali Code).' 'k - ,% . %,
Ii as " owner' of the'properiy,, am exclusively contracting with - licensed
Contractors, to,,conkuct thi. pi6j6ct (Sec. -7044,. Business Professionals
�,Code)"�,
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'-,-,B&P.C. for this reii'soh'
1.,ag.bx. 660'r' ection
" 4;" ik.
Datej SIgAa`turdof Owners Wner,
WORKER'S COMPENSATION DECLARATION.
II hereby affirm under" peinaity'Oif - p6qury on6`6f the following declarations:
I have and will ri7alhtain a certificate of consent to self -insure for workers'
_compensation,_,, as + provided f6r'by Section 3700 of the Labor Code, for the
-,p6rforinance of the work for4hIc'h this permit is Issued.
I haveandwill maintain workers' compensation l insurance, as required by
IL'SM-6n 3700 of the Labor Code, for the performance of the work for which this
permit is.issued.-My viorlibis'. compensation Insurance carrier & policy no. are:
Cani6r LIONPolicy No. me. CoPoli
.
,(This section need not be compi6toid R the
permit valuation is for $100.00 or less).
certify that In the performance of the work for which this permit Is Issued,
.1 shall not employ any person Ih any mariner 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 comply with those provislo
Applicant
Warning: Failure to secure Wo6i;' Compensation coverage Is unlawful and
Shall subject an employerto criminal penalties and civil fines up to $100,000, in
addition to the cost of compe6tatlotni;damiges as provided for In Section 3706
4of the Labor Code; Interest and attorney's fees.
IMPORTANT Application is hereby made to the Dlrector'of Building and Safety f
,,:!or a 'permit subje6t .to the. c6nditions 'and restrictions set forth on his
.-
IpOcitlon.
rl,. Each pe6on upon whose behaii this ippilcation is Imide & each person at
whose request and f6r' wh6se birm6flt Work li'perfoinied under or pursuant to
any permit Issued as.g result of this, apoll6tori agrees to, &, shall, indemnity
lAhold harmlesi thiitltj�bf Li Quinta,-lt6 officers, agents end, employees.
. . I �
C �2.'Any permit issued as a' reiiuli, of thisapplication becomes null and vold if
ft workAs not commenced %Whln!_,1180 diyi-,fror'n' date of issuance0 f SucH
permit, or cessation ofw6rk for 180 days Will subject peihnit to cancellation.
1"I certify that I hive read this kippil6atlon and state that the aboVe inforniition Is
466rr6ct. I agree t6'c"ornply"With all C1tY,'a_'n_d`S'tate laws relating to the building -
cdnstrubtl6n, and'6reby aidth6rlzi repreientativ6s 'of this City to enter upon,
athie ab-ove-meintloned Wproperty f6i Inipecii6h'pdrpos6i. r,� I I . V I
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Ignature (0;,�ner/Agbnt) �.k a
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.,,.BUILDING -PERMITFFHM
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DATE VALUATION LOT -
JOB SITE
ADDRESS'' 191eWo 4 tMOV9*001)
APN -
OWNER
CONTRACTOR /DESIGNER /ENGINEER
i 414-,"-�Mw
jPGAW9ftRNMAL 4606WIMRS
k33 Wlbk� MM774mm-f boitp -
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P.O. xioW
Bo
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5 (180 IS HORHAM PTACE # 0.
LAQ Ai .922513
RANDMW CA_921122
(858)535.1475 CBIS 5023
USE OF PERMIT
MERALBURDING
SEISMIC RETRO-VIT; SLOO, 4: 54.643, 54-M9, 54.635%
$4.661, 54-60,14-M 34.670, 54-683
VALUATION Do t-3
Ergra"Mm COST CYV conri MU MITON
6(a1000.00
PERMIT M SUMMARY
CONSTRUCTIOW ",9 101.000.41 S -OC* 1459.50
STRONUMOTIONFFE-RESID 101-000-241-006 $6.00
MM-TMAL M,14TrRUCn0K AM) PLAH CRECK
LESS T
°
D
I PERM MS DUE HOW
_
j� it `12UO2 T
OF LAQUINTA
COY
FINAN
PECEIPT
DATE ryry
11� �
DATE7 ALE
INsPEC70
I %,
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Badm
UndergrowW Duda
Fomes & Footinp
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
ExhaustFans
O.K to Wrap
F.A.U.
Framing
Compressor
Insulation
Verb
P.L.
Grills
Fireplace T.O.
Fans & Controls
Wall insulation
Condensate i �
Party Wap Firewall 71
Exterior Lath y
Drywall - Int. Lath
41
Final
Final'
POOLS -SPAS
BLOCKWALL APPROVALS
Steel _
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Under round Electric
Underground PI . Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Urns
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:
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1
Final
Willy Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
'Temp. Use of Power
Final
Notice (Perm)
09/17/2002 01:04 7609227550 FARNSWORTH IORO
.`. 09/16/2A92 13:06 7689227550
- — FARNSWC RTH I ORCQ
Verbal Diammiwta.and/or InWUC1IOnS with Cm"Ctor/Architect-
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09/29/2002 12:56 7609227550 FARNSWORTH IORO
Verbal Discussions and/or Instrucsdoris Viii Con'
traetor/Architect:
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09/30/2002 11:55 7609227556 FARHSWORTH IORO
Verbal Discussions and/or Instructions with Contractor/Architect:
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