0002-033 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm underpenaltyof 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. Clasi Exp -Date
V'71_ - lxlo of
Date Si nature Con'racr
OWNER -BUILDER DECLARATION' If
I hereby affirm , under'penalty'of perjury that'l am exempt from the Contractor's
Lice nse Law for the following reason:
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).
1, as owner of the ,property, am exclusively contracting with licensed
contractors to construcii ihe project (Sec. 7044; Businesi &, Professionals
Code).
I am exempt under Section B&P.C. for this reason
DateSt gnature of, Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm. under -penaltY of. perjury ore 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'Codb, for the
performance of the work rk for which this permit is issued.,'
lhave and will maintain "workerfS'&mpensition 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.
.71-ATAR 13-UND
(ilhis"section need not be.completed if the permit valuation is for $100.00 or less).
I certify that in the•perforrriance.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 t�at if I.should become
or. . � I Ir - ., - - .
Subject to the workers' compensationeprovisiong of Sec ion 3700 of the Labor
Code, I shdH for4hwith comply with those provisions .
Date'' P L_( Applicant ,<7)
Warning: Failure to secure Workers' Compensation coverage is unll(vful and
Shall subject an emoloyer.to criminal penalties and civil fines up to $100,000, in
addition to th6 cost of compensation; dama7ges 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-c6nditionb 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 benefii'wctk is performed under.or pursuant to
any
ny permit issued as a'result of this applicaton -agrees to, & shall, indemnify
.& hold harmless.the City of La buinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not-comment;d.withins .180 dayfrom,date.,of issuance of such
ch
permit, or cessation of work O'I'80" 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 coIm I , plTWft,tf-all City, and State laws relating to the building
construction, and ereby authorize%representatives of this City to enter upon
(i �v .
the above-mentioned ,:, prbberty'fool)spectiori-purposes.
W .
Signature (Owner/Agent) ba
PERMIT #
0- BUILDING PERMIT
�-O
UATIE VALUATION" LOT TRACT
JOB SITE
ADDRESS 49-647 iq51FA PALOINO
APNM
114946i3-00W
OWNER
CONTRACTOR DESIGNER ENGINEER
d.
PC) BOX 1716
-VO. -,193 FUUNCHO LA QUfNTAMC
LA QUIN!.'A. , CA, 9Y. 225-3
*`IX !�PjXfA CA 92253
(760)7711,�.941 (;.'But 2!).96
USE OF PERMIT.
SWGILF, FAINdLY DWE LUNG
.
,1FD-LOT .53 PLAN NVRO- Ri RMT DOE 5 N
M NOT ANCIAJDE BLOCK WALL Gil.
POOL. 75% PLAN QHECKYEE._KE0UUfl0N FORIMOJTIVI.�s OF
A
PORCIMPAT 16
QAfkA.QF./CARXJJ<1 710,00 SF
EINTIMU'U'Li'D COSTL 01,' M'114& UMFON1
4
59y030
7
('110NS`rA1X;110t4 RE 101-000-41MOO
PLAN (TWXX M3
ry wrrr ru I It 4:)
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All f VU S246, 1111,
R 115. i4
FE, REM 1M,- K.1 -241-0i]
031RADINZY F 1.0.11-000-423-000
bEVE1(A_T1RJNW1tkCT Ful
AKTf1q lett ILIC PLAr_3YS - Rk-:31C 704-000-12,55-000 $628,41
SISUB-T(Y rill], CO. -STRUCIM, Am!) P1
_N -IN A: N C'4F.CK
ON 4s.
Z
LESS REUETATb' 'Us
hfff EEN 'NOW
RECEIPT
R.7
DATE
B YW/
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
_pv
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
._(Tv /��
Compressor
Insulation
r
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
PO S - SPAS
BLOCKWA
L PPROVALS
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
Gas Test
Electric Final
Waste Lines
Neater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
r.,Encapsulation
Gas Piping
Gas Test
Appliances
Final
C�MMENTS:
X.S dit- 0,&
Final
Utility Notice (Gas)
Y�on`O9-—r�o
ELECTRIC
L APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
110,
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
M