0301-071 (SFD)' LICENSED CONTRACTOR DECLARATION
I hereby. affirm under penalty of perjury that I am licensed under provisions
Chapipr,9.1(commencing with Section 7000) of Division 3 of the Business and.
Professionals Code, and my License is in full force and effect.
Licerise.#' Lic. Class Exp. Date
674M4 E
Date Signature of Contractdr
� /
�WNER-BW|LDERDECLARAOON ` p
| hereby affirm under penalty cxperjury that Lam exempt from the, Contractor's
License Law for the following reason:
( >|, uuowner ofthe property, o,myemployees with wages outheir sole
compensation, will dothe work, and the structure ianot intended oroffered for
sale (Gay.7o44.Business & Professionals couo).
( ) |, as owner of the property, am exclusively contracting with licensed
onntmvmm m �on»�m� mo project (Sec. 7044. evainooa m P,aaoivna|o
Code) '
�) |amexempt Under Section a&PC.for this mooyh_________
bate Signature of Owner
. `
WORKER'S COMPENSATION DECLARATION
^.
| hereby affirm...under penalty of. perjury one of the following declarations:.
I have and,�Vlll rhaintain' a certificate of consent to self -insure for workers'
c . omppnsation,-af,'providdd - fo : r by Section 3700 of the Labor Code, for the
performance of the work for Which this,permit is issued.
I hav ' e and will maintain workers' compensation insurance, as required by.
gdtti(on 3700*of the Labor Code, for the performance of the work for which this
permit.i§ issued. My workers' compensation insurance carrier & policy no. are:.
Cartier.. STATE AMD Policy No. 046-=2-2003
(Thiis6ction 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 pprmit 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,to1he workers' compensation provisions of Section 3700 of the Labor
Code.�
Warning: Failure to se6ure Workers' Compensation coverage is unlawful iind
shall "subject a.employer
addition mthe 000 ufoumponooUon.damagooaoprovided for mSection 37OO
ofthe Labor Cvde.intemmanmatmmoy'ummo.
,
IMPORTANT Application isne.rebvmade tothe Director mBuilding and Safety
for a permit subject to the" conditions' and, restrictions am forth on his
application. .. ^ � �
�s�h��nup�w����/m�a�|m�����m������
whose request and for whose benefit work ioperformed under o,pursuant *z.:
any'ponnitia'uaUasamoukovmiaappno�onog�ooto, mshoU.indomni�
, '& hold harmless the City of uaOuinta. its officers, agents and employees.
2. Any permit issued as result ofthis application Uaoomoa null and void i,
wo,k,ia hot commenced within 1 , from uoxo of issuance o/such
m
p*rnit. or cessation «fwmoo,18odays will subject permit to cancellation-,.
|6emfythat | 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.t o enter upon
the above- mentioned property,f-o-r)nspection7purposes.. -
Si
`—A�—nDate
—.- --_
`
� . �
BUILDING PERM IT f)v. -ot,DATE
VALUATION rZ16JOB
SITE
4VW491 WA CON'911�YEADOR
APNADDRESS
6491-2 i'7OWNER
CONTRACTOR DESIGNER ENGINEERPO
BOX 17 16
79-2.9.5RM01T0.V.0VWADR .LA
QUIRTA CA 922M
L.A ITTA CA. 922,51Q-60)771-1941
CUR 29965USE
OF PERMIT"SIFV
- LoOT 16 PLAN M3. PERMIT I_X5F3 NOT INCLUDE BLOCK WALL.%FF4
DUE TO MU1,TIP*LE- ISSUANCE OF WOMB PL&N TYPECUSTOM
CONSTRAJOTION 41243, 00 ilf.07woalm
COST UP CONSIVIV MI. ONMm.
111 FIRT submtMillC014STRUCTION
FEB 101-000-4157-9,00 $4521,110PLAN
CHW9 PKE OarPLUMBA40
98FSTRONG
MOTION ITS RIMID 3,J6.14J)ZVtL0PF,R
IMPACT FEELEM;
PM -PAID 1W3
$0100IR'
MAL TIER-MIJ! FEER DUE NOW2'-q-i-'2003
'[1'RECEIPT
DATE
BY
ATE FINALED
I INSPECT6N
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
_ 3
Ducts
Slab Grade
_ _
Return Air '
Steel
_ 3 _ 3
Combustion Air
Roof Deck
–a 9– �3
Exhaust Fans
O.K. to Wrap
– 3
F.A.U.
Framing
/– 3
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 —
BLOCKWALL APPROVALS
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
Waste Lines�r� a p�
Gas Test
Electric Final
Heater Final
Water Piping_
Plumbing Top Out
Plumbing Final
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
Gas Piping
_ zO
Pool Cover
Encapsulation
Gas Test
Appliances
Final
Final lf�
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit _
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels L%
Exterior Receptacles (/
GY1
Smoke Detectors
Temp. Use of Power
Final -3
Utility Notice (Perm) = –
COMMENTS: