0006-330 (SFD)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
vozc
C
14600 I3 4 j
Date �r=at- / Signature of Contractor FA
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) I, 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).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code). . t '
( ) 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 1JA11TED PACIFIC INS Policy No. XW.411911345.00
(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 should become
subject to the workers' compensation provisioNs of Section Vb0 of the Labor
lode, I sh II f rthwith comply with those provision
Date: ��?�� Applicant / 4 V
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
& hold harmless the City of La Quinia, 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 enter upon
Tabove-mentioned property, for inspection purposes. Jro r >1� 5r - _-1 1/� �
Signature (Owner/Agent) Date
• 6 4 BUILDING PERMIT PERMIT#
DATE VALUATION LOT *=�� `'00 TRACT
=%9%.90 V29 J 28603+1
JOB SITE API
ADDRESS �s?V vwP.dFt�siri,��ih� 7-�y9� 07
OWNER CONTRACTOR / DESIGNER / EN (NEER
STF,W,N WALIM HONES 911EV N WALKE,IZ 1101vm
7161 iNl.'?iANA,AVG. 7161 3NDIMAAVE
RIV}".R.MDE C -A 92504 RWERSI E CA 92501
(909)784.0840. CBLO 5257
USE OF PERMIT
7W47E 37AtlU �y LYLMJb+ t
(4
C .i 'Y•S4ri
SYD- 1,OT 24 PLAN 2011 PERMIT DOES NOT INCLUDE BLOCK WA)A.S_OR. <: ;•
Foal,, 75 4t?PLAN CHECK FFI"1REDUCTION- FOR. YSSUANCE, OF SAME �"`� r .-,-.
PLAN TYPE 1� i
CUSTOM CONSTRUCTION 2,379.00 SF
PORChMATIO 236.00 Sp
0A11At1ElCARPC?}1'.T (911) / 12,446.00
XSWAAM COQ' GF CC.I,TSi7ft77C`97ON
2W .90
PERKU r),EE I;"iTMtV1.l#.RY
CONSTRUCTION FE2 101.000.418-000 E993.00
PLAN CHECK FW 101-000.439-31.8 $204.59
MECHANICAL IFFY. 101.000-421-000 Is98150
.
E,1.ECT1JCAL, wFF 101-000-420-000 $145.47
PLUM131140 FRE 101.000-419-000 SIM50
STP,01411211 MOTION 1 F, - RMID 101-000-241-000 $20,09
OPLAWNG 101-000.4234000 $20.00
DpV'EWPER. IMPACT F217 $1,907.00
An z1'>! Punic P"LACBs - Rum 7oI.000.255-000 $2,27
BUTS-TOTAI, CONSTRD'C1701T AIM PLAM CFMCI,
$3,590.42
'- LESS PRF•PAR P "S
$0.00
'1'OTAL FE1 W YKES PITE ?"IOW
0,580/42
r
\
RECEIPT
DATE
BY/ � �
D � �
SPECTO
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
_
Combustion Air
�O
Roof Deck
Exhaust Fans
AX_
O.K. to Wrap.L
F.A.U.
or
FramingGr/
gj
Compressor
AV
Insulation
f7A,Vents
I
Fireplace P.L.
Grills
lb—
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
d
Drywall - Int. Lath
d
--Final
Final
POOL -SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBI G APPROVALS
Gas Test
_
Electric Final
Waste Lines �Z}
Heater Final
Water Piping 7~"
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
_
F. capsulation
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 f f
Sub Panels
7
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
JC7