9909-207 (BLCK)LICENSED CONTRACTOR DECLARATION
I hereby affirm under.penalty of perjury,that l 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
/te 5i9. nature of Contractor . t°'`����
OWNER -BUILDER DECLARATION
1-hereby.affirm under penalty of perjury, that I am exerimpt from the Contractor's
License Law for the following reason:
( ) .I, as ownerof the property, or my employees with wages as their' sole
compensation, will do the work, and the structure is no_t.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, Business & Professionals
Code).
O 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 perjuryone 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.
(X 1 have and will maintain workers' compensation insurance, as required by
Section 3700 of the L'`abor Code, 'for the performance of the wo'rk'for which this
permit is issued. My workers' compensation insdrance-carrier & policy.no.'are:
Carrier rTM A Policy No. +.
(This section need not be completed if the permit valuation is for $1.00.00 or less).
(.) I certif .that in the performance of -the work for which this permit -is issued;
I shall In t�mploy any person in any manner so as to become subject to the
workera compensation laws of California, and agree that if I should.become
sub�jr,ct to the workers' compensation prrovision?C of'SeUefffl'00 ofthe Labor
IC 9e, I , o hw' comply.with ges e p vlSlopsj
Kc
A, � Applicant-iU%a�C%`•"
Warning: 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
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 performed under or pursuant to
any permit issued as a result of this applicaton agrees -to, & shall, indemnify 4
& hold harmless the City of La. Qui nta,.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 1,80 days will subject permit to cancellation.
1 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
constryction, and hereby authorize representatives of this City to enter upon
the lSove-mentioned pr e' or/in pection pur�ip es. C,� I
t i nature (Owner/Agent) �r �� Date V
9 r
BUILDING PERMIT PERMIT#
�t
DATE (VALUATION ��tn% SS10 LOT • 445 TRACT•. 2S114 1VJQB
SITE
ADDRESS -78 65 I'M,14 G .F.% -.W R. •�' RIN
APN 1 770-30-029
OWNER
CONTRACTOR / DESIGNER / ENGINEER
N:'t!CHAEL KAPLAN
-260 VIA w C3L. '
35YiibI3 Ct 'Sx��iui 3� -�L CANYON ON DRI VC
L11. Q!J!'AI':EA CA 922.53
C,Kt;F ED,R.A 1, CITY:'. CA S%' 2-34 .
USE OF PERMIT
GENERAL BUILDING . .
230 L.F. ti'' G AkDE'P' 'WAil, AND 100 L -R.— -.Y GARDEN. '4 ALL, CIMV.
STANUAKID
E FT Wil.rrL 150.00 .t
101-000-419-001 5Y8 i.lit>
it
:st.B-Tt7'.?'.F L d'.0 N". �'',}�1:I ON .�iND 6':1+,t1,TR r;.;�1i ECC
. 1.ESIS' I'R -P.r JD FI:I?S
40.00
t
ng, Qi O.lEA'Osiv,
RECEIPTS
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Retum 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 & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs — I
Electric Bond
Footings S?
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
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)