0205-109 (RR)'
LICENSED CONTRACTOR DECLARATION
.I h�obV Um�sadunder pmv�unu��
Chapter 9 (commencing with Section 7000i
of Division 3 of the Business and
Professionals Code, and my License is in * full force and effect.
License # Lic. Class Exp. Date
'^.~v, `°~ ~
1'.1 WQ31
Signature of Contractor
Date
OWNER -BUILDER DECL.-ARATION
I hereby affirm under penalty of perjury that I am exempt from
L�onnaLaw hxmohd�wnO�000n:. '
( ) 1of the loyeoo*hh wages cis their sole'
compensation, will do the work, and the structure is not intended or offered for
sale (Sed. -7044, Busines��& Professionals Code).
11 as owner of the property, am exclusively contracting � with licensed
contradt6 . fs t o construct -the project. (Sec. 7044, Business. & Profess lonals
am exempt under Section B&P.C. for this reason
Date Signature of Owner
WORKER'S,COMPENSATION DECLARATION
I 6ereby,,affirm Linder penalty.'of perjury one of the following declarations:
I -have and .'will maintain' 'a�c*tificate of.,consent to self-�nsvre for workers'
-as provided for bg.'Sectioh,'3700 of the Lab6r*�Code; foe the
performance of 1he.Wor'k forwhich this permit is issued'.
1Y)''I have,,ancl,will� worke-,r;!.60mpens�tion insurance, as required 6y
f,66 3766 8f, the'Lab&.--'Q&d16-' io�th6�pe mance of the work for:which-this
compphsa ion insurance -carrier policy -no. a- re:
permit is issu67d. My'WAges''
(This section need not be.-dompleted if th&,Oeirimit valuation is.fdr�$100.00.'or,'IeSs).
iaw
...'Code, I. shall forthwith co�nply witKthose provisidih.s.-�'-- —7.
Dat6: App
Warriling: Failure to secure Workers' CA pensati6wcove rage"' is un6wfu'l and
shall subject an ernl:,16�,er to criminal penal.ties'and.civil f ines up to $100,000, in
addition to the cost of coh�pbnsation, clamag6s -a- s provided for in Section 3706
of the Labor,Code, inte(est.and attorney's fees.
IMPORTANT Application mhereby made mmebirecto,mBuilding mmsa foty
for o permit subject to the conditions and restrictions om forth on his
application.
1. Each person upon whose behalf this a������u�����
whose �qvm�and for whose bone0m~rk ioperformed under o,pursuant m
any permit issued oua result oythis app|ioovonagrees to, & oha||, indemnity
mnom harmless the City ofu^Ovinta. its officers, agents and employees.
o.Any permit issued as result o,this application becomes null and void if
work is not commenced within 180 uovu from date of iouuunvo o, such
pomoit, or cessation o(work for 18Odays will subject permit moonuanaoion.
| certify that | have read this appxcationand state that the above information is
correct. | agree tocomply with all Qty, and State laws relating tothe building
construction, and hereby authorize representatives of this City menter upon
the above-mentioned property for inspection purpos S.
'
Signature (Owner/Agent)
Date
PERMIT #
BUILDING PERMIT
DATE:- VALUATION LOT TRACT
JOB SITE
APN
OWNER
CONTR,
USE OF PERMIT
A.
5A-j*.'I11)1-5W_1,10 OAK H1111.41
lviAY
cliTy O� LA PINTA
RECEIPT
DATE:'
DATE FIrLED
INS TOR
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
/ _ �
�p(72 i/�/
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 /f �(�J�0
BLOCKWALL APPROVALS
Final _
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 Co, nection
_
Encapsulation
Gas Piping--
Gas Test_---
Appliances
Final
-
Final T
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring _
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.FI I.
Smoke Detectors
emp.'Use of Power
Final
Utility Notice (Perm)
COMMENTS: