0205-104 (RR)_s
1 -104
' 1 hbf by'affirm under penalty of perjury, that I am licensed, under
provisions'of B IL:RIN 7.
r Chapter 9 (commencing with Section,7000) of Division 3 of the Business, and DATE vAWA-noN ioT TRACT
,IN 11J :Professionals Code, and my License is in full force and effect..
s
C c • License # Lic. Class Exp. Date
_.
C39 RESS , 2IL1M. ZQ QAX '. , , , _
1** yy..y� JOB APN
�' vlt-y fi � F J'�i.Tt_ ADD Y r ,
r.. W fir ,• ' '�
`z y ate" b Signature of. Contractor OWNER CONTRACTOR/DESIGNER/EN (NEER
e. q�=
rC O.8 K ° ...r ; • .L'G �7FZ GJ.7+++'�,�+Hi� i�iOW�a -0-UMD O (7AtZOKMN luot ^
!� F` tD ,' : #'' OWNER -BUILDER D '" r
U.� �` P,O, Box 1060 6i-sSa PAI A'NTON XM
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's `
�' �- � License Law forthe following reason: IAQ A CA�THM.RAL Wr t.'A '92262
N
Z (..)• •1, agjdwnecof the property,�or my employees with wages as their sole ' t;76�0332�-811I C'$JI 1t 4511
I - compensation; will'do the work, and the structure is not intended or offered for
I sale (Sec. 7044 ,Business & Professionals Code). USE of PERMIT
(r ) as, owner of -the property, am exclusively contracting with licensed �L�n�
' rt contractors to construct the project -'(Sec.. 7044, • Business & Professionals
Code).
t - R3.11100Y WITH CLASS A MAURL41A, B; moi:
O .I am exempt:under Section B&PC. forthis reason r
Oi,� Date Signature of Owner
`.a Q WORKER'S- COMPENSATION DECLARATION
O. Q �, I hereby affirni:-under penalty of perjury one of the following declarations: trAx,UAio2a���
r I --O • (') � I have and'will, maintain. 6 certificate of consent to self -Insure for workers'
X W . •compensation, as provided for by .Section 3700 of the Labor'Code, for. the .
O Q. ..' performance of the work for which this permit is Issued.
m Q•' U I have and will maintain workers' compensation Insurance, as required by .
S on 3700 of the Labor Code, for the performance `of the work.for which this
11 perrnh is Issued. My workers' compensation insureince. carrier & policy no. are:
,OTA�'8I'ttND_ Policy No. ''. 046-9'a AQg3769 ES"UMAI"ID COST Old C01`�STRDC�'L6N 2,94f6.t�
OD Q PERMIT Fes: �AR'4I
t • (This section need not be completed ff the permit valuation is for $100.00 or less). aDOg pg}1 + j O1 r000 -A1 �B �DCf VIM
O 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 beco e
subject.to the workers' compensation provisions oP ec n 3700 c °
Code, h Ii f rt ith comply with those provisio£t D A o
'rDatg: I Aopllcant
Warning: Failure to secure Workers'.Co overage is nlau al Ptd* . A�AY U r�
shall'subject an employer to criminal penalties and civil tines up to $100,000, in
addition to,fhe cost of compensation, damages as provided for in Section 3706
of the Labor Cod%.Intere`st and.attomey's fees: CITYOFIAQUINTA
} IMPORTANT Applicatiomis hereby made to the Director of Building and Safety F7NANCEDEPT.
for a permit: subject to. the conditions,. -and restrictions set forth_ on his
' application.
`? Each person upon whose behalf this applicatlon•is made &each person at TiXiAx. CONMUM, [ON I�NT1 pI.AN � SMAO
.whose request and for whose benefit work is performed under or pursuant to LM �� Mme'
any permit Issued'as a result of this applicaton agrees to, & shall, Indemnify
& 7hoid harmless the City. of Lo Quints, Its, officers, agents and employees. =-
2 Any permit Issued as a result of this application becomes null and void it AL MMWFMDUE 14O�V >
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
co struction, and hereby authorize representatives of this City to enter upon `
`thd above-mentioned property for inspectl pu oses
:RECEIPT, DATE / BY DATE FIN SPEC
y S^ f
Signature (Owner/Agent) 4 VnP
�* Date '
.;
� - !...�."14��...-�!..�]�- _...•�.:i�-�s�. ..��.... _ - 4 -'�-�.��Ni.!.i�:s.�F�a.-'.1--:—•....�.?—�:�—:.��:,—is��.+��-.�...'.�...�.�r.�..:--+,--:--•`7--�-•.J—�4+—..�
INSPECTION RECORD
OPERATION ,
I DATE
I INSPECTOR
OPERATION '
I - DATE
I INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set &Klim
Unclerground Ducts
Form & Foo&Vs
Ducts
Stab Grade
Repan Air
Steel
Combustion Air
Roof Deck
ExImust Fan
O.K to Wrap
FA.U.
FrwkV
CompressorInsuktion
vents
FirqAace P.L
GrillsFireplooe
T.O.
Fans & C;ontft
Party Wall Insulation
Condensate Uses
Party Wag Firewall
Exterior Lath
Drywall - Int Lath
Final
Final
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
Set Backe
ElectricBond
FooWV
Win Drain
Bond Beam
------------
Approval to Cover
E Location
Underground ElectricUnderground
P1bg. Test
Final Al I(.'
Gas Pipi
PLUMBING APPROVALS •
Gas Test
Electricng
Electric Final
Waste Unes
Heater Final
Water PON
Plumbing Final
Plumbing TOP Out
Equipment Encksure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Comection
Encapsulation
Gas PON
Gas Test
Appliances
Final
Final
My Notice (Gas)
ELECTRICAL APPROVALS
Temp. PowerPole
Undergrow-rd ConcW
Roto WhV
LOW Volta" Wirkv
Fbdixes
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke DetectorsTamp.Ta. Use of Power
Final
Ufik Notice (Perm)
COMMENTS: