0011-087 (PAT)' LICENSED CONTRACTOR DECLARATION '
kreby affivh 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.
`"" "°°° �"".^.a^ =+.""=
510*17 -.B Me 04/30AW
,
"ate Si6nature of Contractor
OWNER -BUILDER DECLARATION'
I hereby affirrrI,uncler penalty of'p'erjury that I am exempt fr'orn th I e Con . tractor's
License Law /m."em"v°"m.""s"`
( ) | of the property, or my employeeswhh wages as their sole
comp�pnsation, will do�the work,and the structure is not.intended or offered for
..sole (Seo7o44.Business & Professionals Code).
( ) |. 'as owner of the property,.am exclusively contracting with licensed
oommomm to construct the nnNmct (000� ro44.�euamProfessionalsooa��ProfessionalsCoUo). ' ' : '
().|umexempt under So�ion ' .omPC.x,,miom000n
Date ig�amre`mOwner `
'
VV�R�ER� ���P�NS�TKJN ����AR/ml�N
�
| under penalty of perjury one of the following declarations:
( > |hav and will maintain ocertificate cfconsent t000V-ino mhx*orlZo
as provided for by Govhon o7oOofthe Labor Code, for the
ponn,momuomthe work for which this permit iuissued.
( ) | have and will maintain workers' compensation insurance, as required by
Section 3700 of the Labor Code, fo,mo performance, of the work for which thib
permit is issued. My workers; oompanmation'inouranndcarrier & policy no. are:
Carrier Policy No.
D�K8��P T ' '
workers'(This section need not be completed if the permif valuation is for $100.00 or less).
I certify that in the performance of th e work for which this permit is issued,
,I shall not employ any person in any manner so as to become subject to the
compensation,'
Subject—_ to the workers'compensation`— provisions of Section—_ —_ of '— Labor
forthwith comply
Da d Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $1.00,000, 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 �adoto the
for 'a ponnn subject to the conditions and motrion000 met forth on. his
application.
1. Each person upon whose behalf this application isnademeach person at
whose request and for whose benefit work iaperformed updo,o,pursuam.m
any permit issued aoaresult ofthis appnoamnagrees to, & shall, indemnify
A hold hann|eaothe City cxLaQuima. its officers, agents and employees.
u.Any permit issued aoa result o/this application becomes null and 'voiU if
work wmis ncommenced within 180 days ,� date m
e ioouonvo such
po,mit, or cessation ofwork for .18O days will subject permit to cancellation.
| certify that | have read this
'application and atatemat the above information io
correct. | agree mcomply with all City, and State laws ,olaVngmthe building
oonmmction, and hereby authorize representatives of this City to enter upon
the above-mentioned �yf i i
Giqnamna (Owner/Ago
'^ .
BUILDING PERMIT"
DATE VALUATION LOT TRACT
JOB SITE''
-3,01D
APN
ADDRESS
OWNER
CONTRACTOR DESIGNER EN51NEER
43-00 VXLKfA=T�
43-640 7E.XX1,
1A IZTdWA CA 92253
PMMDESERT CA 92211,
USE OF PERMIT
0,) aX.P.7 &(1) 9X14 XLWZA.�FOOD L-ATTICE PATIO ""OVER AN PZR
PORCH/1PATTO 3F
PURW. ir FET SUMMARY
PL14N CHECK FEE $4W95
STRONG MOTION FEE - RESID 101-000-241-1000
Jf
RECEIPT
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
Framing
(('��L� (�'�'�
F.A.U.
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
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
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: