0010-215 (RPL)_ LICENSED CONTRACTOR DECLARATION
i I hereby affirm under penalty of perjury that I am licensed under provisions of
{: H. Chapter --9 (Cortimencing with Section 7000) of Division 3 of the Business and
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N W W - Professionals.Code, and my License Is in full force and effect.
_'-License # Lic. Class Exp. Date
r- 108 1 PIC
15�61 28
oZ r— Date '` f'- c ' ` Signature of Contractor -- - 1.�.-
CO O r�
r- V ) OWNER -BUILDER DECLARATION ,
HLLI I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) . License Law for the following reason:
Z ( ) 1, 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).
.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
LO
"N Date Signature of Owner' -
O•�
�—CL Q WORKER'S COMPENSATION DECLARATION
o 2' Z I :hereby affirm under penalty. of perjury one`of the following declarations:
Lo �< 0 (.) I have and will maintain a certificate.of consent to self -insure for workers'
X W compensation,-as_provided for by Section 3700. of the Labor Code, .for the
m � Q performance of the work for which this permit• is issued
Q C) (: )'_I have and will maintain workers' compensation Insurance, as required by
-Q. U .. Section'3700'of the Labor Code, for the performance of the, work for which this
Il �' HY permit. is issued. My workers' compensation insurance carrier & policy no.`are:
.Z Carrier r x i PolicyNo:'
oo`,� MN',,P61N1"+ , f�G 0`�-43if�fi3G� fik6t' .t
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(This section.need. not be completed if the permit valuation is for $100.00 or less)'
,I certlfy.thatin the performance of the work for which this permit is'issued,
•.. I shall. not, employ any person io`any manrierso as to.become subject'to the
r ; workers' 'compensation Jaws of California, and agree that 'if,I should become
r~subject to the workers' compensation'provisions of Section 3700 of the Labor
Code,.l shall forthwith comply with those provisions.
r
bate :' -Y Applicant- »4,
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 fo 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• -fort h on his
application.M
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 to Quinta, its officers, agents and employees
2: Any permit issued 'as a result of this application: becomes null and voidif
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
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) per" "" -Date �r c�.641
PERMIT # .;
BUILDING PERMIT
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DATE "j/ J( -,/,/VALUATION LOT TRACT ..
JOB SITE—' p
-APN— . -
ADDRESS
OWNER
CONTRACTOR/DESIGNER/EN (NEER
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s S
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R01 Box 171 i1 �
• 44-! 2-J JOYNT'8+�:i't.6 Y,L'+, 0A '
LA QATu+? CA.. CA .:'22 53
PALMJY.E6%Rl 'CA 92260
C16n.)340-9000 cwdf 355
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USE OF PERMIT
I°•C1('i:1, �.�ttTl"_>Jt%Ed. "+��-'.,13.
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D4 0I,ACE, AT PRR PLASTER Mfftt:nryo,POOL ?op:iay;9ew L?lmosL"n.
Is Ha1'.I_dC°V1jDMY its THIS f"Jt?R1IT
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"NWAIMAT XT CCAU OF CC MTR C°Y10N
MAN C1d>;.a. X PES 11011-000-4,39418 $1117100
G�'ppI"u��t1��+3pp:11��Y'd/A'�C••F,.t;�J77C'gr�01�44p7FEE,' i�0yl;��000--4[ 18-�/(Y100:' ��1+6a.AOt4
p�yy'yy
i1.¢L".. 5"M7.tal L'AL FF4 -� F.�C.01, 101^0i/0••, 21,',000 .` 324,00
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11,11CTRICA.1; FRE, -- POOL'. 101.006 420-0 00 30:00
..PLUMZ'11DICf FEP •> POOL 101-000.419.000 =00
�,1'ti3-T(3'CAL CaONO T'RUCYMCM AND PJAM C23}►K
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SITY.Orr
RECEIPT
DATE _.
13Y" n� jF 1
DATE FIN ALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
c
BUILDING APPROVALS
MECHANICAL APPROVALS
et 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
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover '
Equipment Location
Underground Electric
Underground Plbg. Test
Final I I
Gas Piping
PLUMBING APPROVALS
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
�..— /� 5
COMMENTS:
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)