9609-128 (BLCK)` LICENSED CONTRACTOR DECLARATION `
| hereby affirm under penalty of iu''tha|*anlicensed under of
1-- Chaoter 9 (commencing with Section 700o of Division oof the Bu �nesoand
m UJ Pmm�uiono|oCode, and myLicense ioinfull force and effect.
cn License w uc.olasm Exp. Date `
LO C29 �B
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(0 6)
OWNER'Bu|LDERDECLARAO6N
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| hereby affirm under penalty ofperjury that |amexempt from the Contractor's
+'
�� License Law for them|lowngreason:
Z ( ) 1, as owner ofthe property, mmyemployees with wages astheir sole
compensation, will uothe work, and the structure isnot intended o,offered for
sm|e(Sen7o44. Business & Professionals Cvd«).
( > |, as owner of the property, am exclusively contracting with |icanaou
oommomm to oonmmm the project (Soo. 704*. Business & Professionals
Code).
() |amexempt under Section ouPC.for this reason
ul__�______
C\I..
m o�o Signature m Owner
m \
<WORKER'S COMPENSATION DECLARATION
CL
C) �eZ | hereby amnn under nvnuny o/ perjury one m mo mnvwno declarations:
LO ()|xamanuwmm�mainavomnoa�moonoommoo�invu,o»o,wmmom'
X UJ u' vomnonoexion, as provided for by Section oroo of the Labor Code, Jo,the
[)pononnanuoovmfor
`" *t | have and will maintain workers' compensation inoummoo. aorequired by
3700 of the Labor
the- work, for
��(J Sectiondo. � hmo ofmoh this ' permit io~ISiOdrMy\mormam' compensation insurance ogmer&^ponC9 no. are:
Carrier Policy No.
r- 0 `
< (This section need not becompleted ifthe permit valuation isfor m00.00mless).
_J ( ) | certify that inthe performance ofthe work for which this permit ioissued,
| shall not employ any person in any manner oo as to u000ma subject tomo
workers' compensation laws o,California, and agree that i, | should become
uu��mworkers' Go�iondroomthe 4ouo�
Couo.| shallforthwith oomv|vwith those provisions.
Date: Applicant
Ann|icun
Warning: Failure msecure Workers' Compensation coverage iounlawful-and
shall subject anemployer mcriminal penalties and civil fines upto$1oo.000.in
addition mthe cost o,compensation, damages odprovided for inSection o7o6
mthe Labor Code, interest and attorney's fees.
IMPORTANT Application iahereby made mthe Director mBuilding and Gof ety
for a ponnn subject to the conditions and restrictions set forth on his
application.
—�� 1 Each person upon whose behalf this application is made meach person ox
-~
whose r6qummand for whose benefit work io performedunder oipumuunt"m
any permit issued as result o,this apnnoaovn agrees to, m oxan. indemnify
m hold harmless the City of Lo Ouinta, its officers, agonmanuemp|oy000.
u.Any permit issued avoresult n,.mioapplication becomes null and void i,
work is not commenced within 180 doVu from date of issuance of such
pennu. or cessation of work for 1uodays wm subject pa,mumoanvvn,xion.
`~
| certify that | have read this application and state that the above information iu
° vo,mm. | agree tocomply with an City, and State laws relating tothe building
construction, and xvmuy authorize representatives of this Qty to enter.upon
the above-mentioned H
`
|
Signature (Owner/Agent) ~°~ oate������Z��
/
'
BUILDING PERMIT 9609-428 4109
DATE 9/ 17/9,6 VALUATION LOT. TR�CT
JOB SITE 44-424) VIAIWs L SOL.
ADDRESS
OWNER
CONTRACTOR DESIGNER ENGINEER
SIM N.T.Ep
EXT 4A
OF HIM, SIX -ND CONTS"I'Mic".10N
POW 3.. F433
PALM DESERT CA 92253
PAL&I DESEM' CA 92211
USE OF PERMIT
E—STMATED CXYST OV CONSTRUCTION
5,1100,w
CON151RU(I"TON T16311 101_0004tg-ft) S7100
LESS PRE-PAWFEES
$6.00
Tikl, 11CRA11T FEES -ME, NOW
$7100
Vrl
CEIPT
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
Return 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
BLOCKWALL APPROVALS
POOLS -SPAS
steel
Set Backs 4 z
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING A0Pk0VALS
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
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)
COMMENTS: