0002-361 (SFD)_ 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 # ,' Lic. Class Exp. Date
' 714188, B `� �fr � iCf3ii2td
Date Z i" D Signature. 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). w
{) I am exempt under Section B&P.C. for this reason
Date esignature 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 3700 of the Labor Code for the
perforrnance,.of the work for which this permit is issued: $ s
(�I have and will maintain workers' compensation insurance, as required by
,o Section 3700 of the Labor Code, for the performance of the work for which this
permit,is issued. My.workers',compensaiion. insurance,carrier & policy no. are:
Carrier { �+�q 1 - Policy No. ,w{`'
A'OJ.r�d.riu .P1K�3d.t'—'+.1�Va�.l, - • NVIC .,9` 400) . —UL -
(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'shall forthwith comply with those provisions.•-)
Date:^ /.t /�rvJ'J Applicant
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 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 is performed under or pursuant to
any permit issued as a'result of this applicaton agrees to, & shall, indemnify
. & hold harmless the City of La Qulnta, its officers; agents and.employees
2: Any permit issued as a result of thls application becomes null and void if.,
work is not commenced within 180 days from date of Issuance of such
permit, or cessatlon of work for 180_days'wlll subject permit to cancellation. .,
I certify that I have read this appllcatlon and state that the above information Is
correct. I agree to comply with all'Clty,',and State laws relating to the, bullding
constructlon, and hereby authorize representatives of this City to enter upon
the above-mentioned property for Inspection purposes. 1
Signature (Owner/Agent)'n` ��=�'j'.1" Date [; .
..BUILDING PERMIT PERMIT
$ 1 yA
DATEVALUATION LOT TRACT
S106,397.160 239951s,
JOB ADDRESS.=�i+7V T�e R�DVier.
APN
1 4
OWNER _ -
CONTRACTOR/DESIGNER/ENGINEER
CENT-URSi
s�'.IE `+t,i PiAi C,::liIMITH111 COx1',d1YiUM }Ti.Gw'1 .
153 SO. °i3" �"'CitE .C, S!` . f 00 ,.
±S3'Y SO. "L" Mum, an. a�290 - •"
SAN iBERN4RDINO' CA 90408
SAN BERN.t1.R.,DIN10 CA. 92408
OW381-6007 CRU 22.20
USE OF PERMIT ,
Sid` GLIL'FAW1 �'c'DWELLINd
fir T3- I..t T 80 14.AN n PHWvfi TDORS NO T n4 LuT)e FAL 0 C WAL L OR
SAT+T3 PLAN V'<'PE, °
CON"STRUCTL014 `F
PORCRMA11.0 32.00 "qr.
GAIIf'l4.T_I:/C,A11i"ORT 440.00 Sll•-
CON:'!TRUC IfON.t+EE $Gr�.00
YLIAN Ga_ IS FRE !(fit -0000-439-318 51373.71)
'kffC.14AI•d!•_.AL FTS <S $47.00
;
ELECTRICAL FU J.01 -000-42Q-000 S119-90
131AAO Alit -0004.9-000 �p. x '•�
/..fJ1dX137.25
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ART EN PU13t 1L PLAM - RE81,1370f.-000-'?SS-000
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RECEIPT
DATE
BY j , r f f* VA
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
14,
Ducts
Slab Grade
S --L
Return Air
Steel
, t at . (90 •
Combustion Air
Roof Deck
(p . 11-a
Exhaust Fans
OX to Wrap
-i -' AX
F.A.U.
Framing
8h cz_�
Compressor
Insulation
fj-$�Qa CQ�
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
Gas Piping
_ PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines`
.?-o - oo
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
111242
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.I.
Smoke Detectors
Temp. Use of Power
Final ( (Y21OQ
Utility Notice (Perm) o