0205-105 (RR)& hereby affirm 'under penalty of perjury. that I am licensed. under provisions: of,
. ,Chapter 9 (commencing with, Section 7606) of Divislo'n 3 of the Business and'
full force and effect.
Professionals Code
and my License 1s In
�s.h LIcense # ass Exp. Date.,
'457 Z"
*4 ; I
c
511
W.Date Signature of Contractor
.
WNER-9LIIL6ER'DE N
G
il hi0ebV?aff lhm Zinber oenalty�of perjury',that I am exem'ptfromlhe Contractoeg.
'LI66fise Law reason-
is,owp&of:th6 property, orm
� 'j:empl6yees With wages' as. their, S016
'
�pqmpensa, ion, zwill do:tfiw work, and the structure Is hot iftinded or offered for
rsa s'
* le,(Sec. - 7044,-B6sInes& Professionals Code):
owne of the! property, .am exclusiv6ly�0ntracting'With licensed
4'd�6htractoij�t6l6iD'n'str6ct -Ahe., project (Seca 7044, business & Professionals
',66aer'•Se"c'tio'n. 6'&R'C. foe thig-reagon
Signature, of Owner
7
WORKER'S COMPENSATION .
DECLARATION.
R IS
Kereby''6ffi ir, - under-- penalty, of -perjury oneof the following declarations:11,'
a1nd,WIWmaihiaiei ii'certi icate,o consent,to'selMnsure for workers' -
id'f' JV-§ectl�h'VOO - "
�compensatlon,` as'provide . or I of Labor Code, for the
�pdrformance ofithework f6e4hlch ifiii permit isissbeil.`
I have and .will ..:m6i6'ta:lh,workers' compensation: insurance, as required by
'-C�de�. for the performance; , of 6 work for -which this
37 of Ah6,Laboi pe ce 8
,;,perm
P . •, 1 11. _� W�,w6rkersi',compehiabon, insurance carrier & po icy 1 no. are:.
it, is issued.
C 'No,
�affldf,'. STATS �.,i Policy (W6.91-0095269
W."
(((This section, need WthipermltvalUation is for $106.00 or. less).`
I certify.theit. 'fi permit is Issued,
In t woerformance o the work forwhich this
-all not t em . ploy.'any,i,person , in a ny manner anner so I as'to become Subject to the
Yworkers','c,ompeni6tion,idw6;,oi-,Callf6rnii,,�i6d"a6r6e 1hatif I'should become
ject -to."th6 workers 66iiip'e-n,s,ation,p,-ro"visi,or,'Is of,,Section, 3700, of the Labor
all comply withihosi-pr�.Visr
p, Fallufbtoi,6666-4 W&kirk
tion coveraga ls,Uhlawful.and
i " fl '
)Ject an,drnployerto�crlmlnal p6naltels and civil nes.00to'$1100,000,16
t 6,t k 6cost 6 f compensation da6lagesas:pi6vlde.d for In Section 3706
iboF, 666,- lhiirdit and attorney's fees >
rANT- 406il6ition-ls hereby"made to'the.Director of Building and Safety
eimit forth on,. his
:h,oet6bh�Ooon'Fwhoi6e'behailf,ih'ii%ippli'c'*a'ti'o"n"'Is'+'m'ad9'&"'e'i'cfi'per'd�ozn at
f I
i�equest.a or whose.benef t w6rk.ls performed under or pursuant to
jrmit 1619_66d.as'ii result of. this -io.-pll'cat'on',aor'ees,.to*,.&. shaill, Indemnify
I1h'armless the.Clry of ;La Qulnta is officers; agents and employees.
'and void If
I S,
not commencedM'Ithln� 180 days .',from,"-date Of .Issuance: of such
Or cessation of.'work 'f6f1`8d..days _will' subject permit to cancellation.
4
h9f I,.hiV6,'iea'd th'1'6,'iip"0'1'1'catl6h,ihd�i"t6ti th'd,t.the',above�.Infor�natloh Is
I agree fd.:d6mpiy with i(lClty,-'and-'Sti'3te;;IaWs;relatln§,t6'thd building
,tion*i. a se
arIdf hreb� y uth6rIie repi�q hiativei,of,thip iCity to enter Upon
re-'mentionied property for lnspeq Ion purposes..
RECEIPT. DATE
'Al
'l ee '(Owindr/Ageht) bate'
r
PERMIT #
s 1i MINGIPERMIT.
# �JQt�7f.
BUIL
DATE LOT, "'TRACT -
14
t.L. 7-;,- -S
0"
JOB SITE
ADDRESS C)AX HUX J 3,
OWNER
CONTRACTOR I DESIGNER I ENC 4IN PER
PGA W.E.8"r 91=MMAL ROME,0WIT08
TT_fl11RM_0_19M.D:6F CALMMIA"INCA'
'Rolwx 1060
EN9.
67 0JWY0HbRM
I A QUMA
RAL Ctry, CA;,�2w,2:
USE OF PERMIT
'0M4ENALDMLDW0- -
M-RODY WITH CA..' ".A MATER.LAI, & M,00. It: 54-337, 54-1231.
54731 4,301. OAK H I ul�
VAU)AT)ON La
wrainu cbsa* (W con's—mucrion
DU
24W
Mri6v. mm - _L? 10L-000.418-0%)
!J
wA .
XY. F LAQUINT,
FINMICIEDEPT
WR4WAL CONSWILYCTION AND PLAN CMCAC
W 'PAWFM
M I PRE-
TOTA� MOW FEES DURIVOW
Od
7W
1
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 -
OX to Wrap
F.A.U.
Framing
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
BLOCKWALL APPROV S
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: /
-