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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
/De/ I " " K, 119
at, Signature of Contractor -
OWNER-BUILdER D
I hereby affirm under penalty of perjury thatram�6xempt from the Contractor's
License Law for the following reason:
1, as owner of the property, or my'employees with wages as their sol6
compensation, will do the work, an,*d the structure is not intended or,offered for
sale (Sec. 7044, Business & Profdssionals Code).
( -) 1, 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:
Carrier Policy No.
ATH f CO.
'NS ".0 .66(v
(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 shpuld--bec�me
;_b ct to the workers' compensation provisions of Sectiom-3700 of the Labor
0 j: I . .--- .,.
d yl§h,�ll fort�6�ith comply with those provisions—,.-I;o',
Date:' L�,Appiicant
Warning: Failure to secure Work rs' nsation coverage is unlawful and
shall subject an employer to crimi . a] enalties and civil fines up to $106,000, in
addition to the cost of compensd ion, damages as provided for.in Section 3YO6
of the Labor Code, interest and attorney's fees.
IMPORTANY 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 pursbiinf t6
any permit issued as a result of this applicaton agrees,to, & shall, indemnify
& hold harmless the. City of ia Quinta, 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 rep resentativeslorth is City-to'enter upon
th a6ove-mentioned property for, inspection.puepose
Signature (Owner/Agent) Date
PERMIT# CONTROL#
BUILDING PERMIT
902-JJ7
J.5 3 5
DATE VALUATION LOT TRACT
JOB SITE
ADDRESS -45485
604-280-047
OWNER
CONTRACTOR DESIGNER ENGINEER
(.1, F."Up, Y C IKAIVELI.
'1�
Y CROVVE, Uld MIM&MN 1 -.8
rr r,
1333 SO- ` D" Y11 � ET, S` W, WIN
1 j�5 so, " UP ST REF3-',,'S*F8 6204
SAN 8HRNARDINO' C -'A 9241118
SAKI BE RNARDINO CA. 9-408
I f,007 2120
BUNJAMV AGUILAR A4LIOOCIyk
USE OF PERMIT
5459 PASSERO AVE.'
1TUeOr (ONSTRUCTION UW,00 SF
POttC."M ATIO 50.00 8F
QAkA.G& CARVX)RT 420.00 SF
F TIM- -F -911r,"VCTIOIN.
.S TEDCOIS .(YIPCON,
106�637.00
CONWRUCT 10-NIFEE I o 1 -000-41 9 -MIO
PLA N CITEKN rUP, 191-000-4V.-319 $54936
Ael E CVLAJ�41 CA L P IWES 10 1 - 0 W –1 If, I - &117.00
'101-�1*420-000
io 1 -000-419-000 $127.50
STMONO MOTION (RES) !01-000-241-000 $10�66
GRADING 101-OM423-000 $20.0
TNFkA,ST(1C1'(Mfi 225-0110-443-342 $2.384,231
MU fN PUM P1-ACt--,8 (:RES) '70J �-M $16.59
AC -000-25 0
ippdIDAL CONMUCTION.AND PTANCHECK
$3,918.39
-SS -�-N -T'
LE PRE UD T ES
$0.00
19961'O.T'Alt" 1"llm-mut. r k'ws Duc rqo, W
al)
C -T'Y-O
REC EIPT
DATE
DAT E FINALED
R
..4 4
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION ___f
DATE
TINSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
&_3 Av I
ExhaustFans
OX 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
4
Drywall - Int. Lath
Final
Final
BLOCKWALL APPRO% S
POOLS -SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
j /
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX 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
Fbdures
Main Service
Sub Panels
E)derior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
1.111lity Notice (Perm) C/ f
COMMENTS:
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