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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#, ;3 Lic. Class Exp. Date
7776.99 b
Date Signature of ContractoA A/-�'�"��"
7.
OWNER -BUILDER DECLARATION" '
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 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 (Seca 7044, Business:& Professionals Code). ,
( ) I, 'as owner -of the pioperty, am exclusively contracting with licensed
contractorsAo construct the project (Sec. 7044, Business & Professionals
Code). :..,�•
() I am exempt under Section B&P.C. for this reason
Date Signature of Owner
Q WORKER'S COMPENSATION DECLARATION
p ? Cr I hereby affirm under penalty of perjury one of the following declarations:
p () 1 have and will maintain a certificate of consent to self -insure for workers'
X w IL compensation, as provided, for. by. Section 3700 of the Labor Code, for the
. Qperformance of the work for which this permit is issued.
CO Q U. O I have and will maintain workers' compensation insurance, as required by
C5U, Q ' Section 3700 of the Labor Code, for the performance of the work for which this
D.: ,LO H` permit is issued. My workers' compensation insurance carrier & policy no.' are:
z Carrier . J,1bB__RTy MUJ iAL p, . Policy No.
W0,202DO04723012TI
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J'(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 3700, of the Labor
Code, I shalfforthwith comply with those.pro I ons,
Date: ✓�' �: ApplioantAe7: ro.I
Ile
Warning ;Failure to secure Workers' Compensation coverage Js 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
R whose request, and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicator agrees to, &'shall,+indemnify
& hold harmless the City of La Quint-; its°'officers, agents and mgloyees.
2. Any permit issued as a result of this: application becomes null and'void if
work is not commenced within •180 deys..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.'l 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. a_
Signature (Owner/Ag ) A%:<,rr�D"` """" Dates�� "-
BUILDING :PERMIT PERMIT # S
DATE : VALUATION LOTw. `�� TRACT
JOB SITE `'�„ APN' `
ADDRESS >'W i!��nXa�s7
OWNER 4—+i..�7 CONTRACTOR / DESIGNER / EN (NEER
,73.121. N'tW. W;�,?��TO 100. 73-121
s' AI.�E(I` `UMI'' M29J VAt.U,fJF.'a RT t CA 922,60
-%W9 MIA 3832
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USE OF PERMIT
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�k0'• 1.O1' 1fA"�ai�"�'!k�.i," o-.1. l�:li.�yfsi I ODES NOT 41401 UDY, fFb.6+ucel'
'C°c►A144% P001; SPA OR, DR1VNWAYAPPR:OA,0H
C<UOTO'N C"Cild97}1.UCTPON 3I.M.00 'sF
PC'atriC ►-i/1°,fk;a O , 4'0,00 SP
cog (Yir C-01Yha1 j"x�7(1MOtV 2 l5a4Me7o, .
CONSTRUCTION TITZ 101.000i -41B-000 1s,k15,to
PLAN CHECK a",18, 'tell -00"- '39-318 $1,J69.19
t4 muwIcAvra, 1031070-421«0010 $1.37.50
Ei.YX ICA1.rig 101.-0034MWO $IM29
PLi3M'SINOFVY- 101-000-4.19% 00 $9ti3,�g
u'f'i;`ONCg9t 0T10HFEZ R,IIS ID X01 -000 -Ml -000 $27.41,
011ADINO WK IM 4500.Q31000
1. F,VELC1PZk3. V1P'A4,C1' SST: $5,�3tt5.00
Afrr YN PUBLIC PLACES » RE011. Z70-000-445-000 SAWY.0
4 �y
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SUO-'1.`as"i7., L C ONtffRITC."XIt`SNA:1 D k LAW' CXI $5,445,89
LF123 T11NYF_FMDV9E5 TO, 00
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OF LAQUIf6TA
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INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms &Footings
Ducts
Slab Grade
ReturnAir
Steel
Combustion Air
Roof Deck
-�
Exhaust Fans
O.K. to Wrap
_
F.A.U.
Framing
_
Compressor
It
Insulation
.i
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
on
Exterior Lath
¢
Drywall - Int. Lath
_
- — — —
Final
(1000,
_ _/Final
US
_���
POO- 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
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Z - •o
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
. a 3 57
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
/
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
_
Low Voltage Wiring
r
Fixtures
Main Service
/
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
- J
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Nov'. 5. 2003 9:54AM CUSTOM SYSTEM,TECH., 760 345=8405.1 No -0872 P. 2
RIVERSIDE COUNTY FIRE DEPARTMENT: j
IN COOPERATION WITH , 1,
CALIFORNIA DEPARTMENT OF FORESTRY'
AND FIRE PROTECTION
. t
RIVERSIDE OFFICE INDIO OFFICE
i 4080 LEMON STREET, 2ND- FLOOR 82-675 HIGHWAY 1.1
P.O. BOX 1549 t 2ND FLOOR
RIVERSIDE, CA 92502-1549 INDIO, CA 922(1
(909) 955-0777 (760) 863.88E 6
FAX (909) 955.4888 " FAX (760) 863-7012 '
JOB. -CARD
THIS.INSPECTION RECORD MUST BE AT JOB SITE t !
WITH THE APPROVED SET OF PLANS
Owner��_ Date 8 03
1 y ,
Looatilir—
r. -
Case No. 1Ap-n7•3P-1yz
Sprinkler Company
j
Underground Visual Data Inspector
(Joints and Thrust Blocks Must Besed)
Underground Static oak Inspector '
(200 PSI For 2 Hrs. Prior to Inspection •p ) +; , t
t
Underground Flush D e Inspector
Overhead Static , ate Inspa Tor -
(200 PSI For 2 Hrs. Prior to Ins tion Time)
t ,
Overhead Final Date Inspector 4
Fire MIdergro
staller
und ual Date Inspector
(Joints and Thrtrst locks Must Be Exposed)
Undergroun Static Date v Inspector
(200 PSI For 2 Hrs. Prior to fnspecGon Time)
Underground Flus Date Inspector
i
Extinguishing System Ins Iler
F nal Date , Inspector • d
Fire Alarm Installer Sr
Final Date Inspector
Tank Installer a
Final Date Inspector • !
j FUEL MODIFICATION t
I_
Final Date Inspector
DO NOT 0 COPY THIS STRUCTURE UNTIL 1
t AFTER FINAL INSPECTION BY I
BUILDING AND SAFETY
• i
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Nov'. 5. 2003 9:54AM CUSTOM SYSTEM,TECH., 760 345=8405.1 No -0872 P. 2
RIVERSIDE COUNTY FIRE DEPARTMENT: j
IN COOPERATION WITH , 1,
CALIFORNIA DEPARTMENT OF FORESTRY'
AND FIRE PROTECTION
. t
RIVERSIDE OFFICE INDIO OFFICE
i 4080 LEMON STREET, 2ND- FLOOR 82-675 HIGHWAY 1.1
P.O. BOX 1549 t 2ND FLOOR
RIVERSIDE, CA 92502-1549 INDIO, CA 922(1
(909) 955-0777 (760) 863.88E 6
FAX (909) 955.4888 " FAX (760) 863-7012 '
JOB. -CARD
THIS.INSPECTION RECORD MUST BE AT JOB SITE t !
WITH THE APPROVED SET OF PLANS
Owner��_ Date 8 03
1 y ,
Looatilir—
r. -
Case No. 1Ap-n7•3P-1yz
Sprinkler Company
j
Underground Visual Data Inspector
(Joints and Thrust Blocks Must Besed)
Underground Static oak Inspector '
(200 PSI For 2 Hrs. Prior to Inspection •p ) +; , t
t
Underground Flush D e Inspector
Overhead Static , ate Inspa Tor -
(200 PSI For 2 Hrs. Prior to Ins tion Time)
t ,
Overhead Final Date Inspector 4
Fire MIdergro
staller
und ual Date Inspector
(Joints and Thrtrst locks Must Be Exposed)
Undergroun Static Date v Inspector
(200 PSI For 2 Hrs. Prior to fnspecGon Time)
Underground Flus Date Inspector
i
Extinguishing System Ins Iler
F nal Date , Inspector • d
Fire Alarm Installer Sr
Final Date Inspector
Tank Installer a
Final Date Inspector • !
j FUEL MODIFICATION t
I_
Final Date Inspector
DO NOT 0 COPY THIS STRUCTURE UNTIL 1
t AFTER FINAL INSPECTION BY I
BUILDING AND SAFETY