9907-427 (SFD)LICENSED CONTRACTOR DECLARATION
.—
I hereby affirm under penalty of perjury that lam 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. Class / Exp. Date
16/atef » r Si nature of Contractor✓��
..' OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from.the Contractor's
License Law for the following reason:
( ) . I, 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).
( ) I, as owner of the :property, am exclusively contracting with licensed
contractors to' construct the project (Sec. 7044, Business & Professionals
Code).
O I am exempt under Section B&P.C..'for this ,reason
Date Signature. of Owner
WORKER'S'COMPENSATION DECLARATION`•
I hereby affirm under penalty. of perjury one. of the. following declarations:
() I have and will maintain a certificate of consent to self -insure for workers'
compensation, as provided for.by Section 3,700 of the Labor Code, for, the
performance. of the work for which this permit is issued.. ;
(� I have and will maintain workers' compensation 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:'a're.;
Carver Policy No.
STKrF, RAND
(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
worker 4compensation laws of California, and.agree.that.if I should become
2der
e�to the�workker6' compensation prpovisions of action 3700 of the Labor
I�sf�all f d :fwylh comply with thoSeip o �siori ,
e: APPlicant t.Yt
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civiHines---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
whose request and for whose benefit work Js performed under or pursuant to
any permit issued as a result of this applicaton agrees to,.& shall; indemnify
& hold harmless the City of La,Ouinta, its: officers, agents and employees.
2. Anj permit issued as a result of this application becomes null and void if
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
constyction, and hereby',authhorize representatives of this City to enter upon
the above-mentioned property -for i sp I n'pur�oses p " ,
'Signature (Owner/Agent) Date
BUILDING -PERMIT PERMIT"
rd
DATE VALUATION LOT @i�4`? TRACT
j q
JOB SITd
APN
ADDRESS
OWNER CONTRACTOR/DESIGNER/ENGINEER
O7 IPHA/,'f"f AND %V111LAMS ASSOC- - Ift--1C (XAPHA,ig TAXD V1%IsL1AMS . StJt".,
P.'fC. .
71•SYKII AVENUE OF THE STz rES '71-qW JkVFNUF GF UTF S'l:AIM—S.
i'A.i Iw4. n E3 T C.A '22!' i�#4L(LIVI eEi,3��I;1'
f �Aj.
�j,9? 5?{{d;l [1yr,
USE OF PERMIT
3F -D - LOT 92, PLAN 4A, P Mfff DOES N'<.ti'T XNCL'r 09 8L OCK 'tiA1AJ1L OR
;
POOL. 7VX,6 PLAN C14RCK' FEE FOR MMMLE 15,511 CE' C1F SAME PLAN
TYPE
• f
TRAiC f a ONSTRIL C fTON 20 098. W s>.E
PORUllWATIO
ESTMIATED MVC OF CONSTMXTION
1131160.80
PERMIT FU.SUMI c1Ry
COtLVIMUC,'T(C>NFM $74.1,00
.,
PLAN CliECK FEE, 101 -OW -410-318
l
rafl>;0'1ANfCAC. 1'E IepL10f;042.1f.-4)013
_
Si.ICTRICIAL FEF IOl.'000-420-NO
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min 2 +10.1-000-423-0(K)
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A.iV�pi'.pf�Y["f4�F7��1]'d�11•�Vr�.cpLuBl[o'1t.T.'rnFEFI.y . 725-000-44431-342 .�fi'IyR7.ct/fAr.�n�
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. I O7l, RL YRANIfY �,lUNY DU� NOW
s
RECEIPTDATE'
B,Y,.
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
t> —Zg-29
Exhaust Fans
F.A.U.
O.K. to Wrap %f�_�' �'
Framing
�, �_ �9 �+�
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 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
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
Sewer Connection
j
�Z �6 `
Pool Cover
Encapsulation
Gas Piping
Gas Test
2 r S fr
Appliances
Final
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.1.
Smoke Detectors
Temp. Use of Power
Final -
Utility Notice (Perm) W !{