0205-104 (RR)If—
hereby affirm 'uhdO oehaltybfpelury that'l am, licensed under pr sions'of-
Chapter 9 (comini rcln`g with Secliori,7000j of Division .3 of the !Business andt',f,
-Professionals Code, and my Ucense is In full force and effect,Ucense # uc:ciass 41E�ip. Dat
•
Signature of
OWNER-BOILD!ikb�
hereby affirm undei.'penalty of perjury that I am exempt from the Contractors
License Law fo- the foll6wirig reason:
fora
O
he
thi
property, or my employees with wages as their` sole
compensation, will do the work, and the structure 16 not intended or offered for
-sale (Sec. 7044,,,Business & Professionals Code).
1. as owner of the property, am - exclusively contracti , ngl with licensed
Contractors to,bonstruct the project (Sec..7044, Business,& Professionals
Code)
',(-)��41Rexotni
'ptur�eS6'oibn-b&R'ef)br'thfsreas-oh,,'
Sign
Date' * -
�ature of, Owner
WORKER'S COMPENSATION DECLARATION
-1 hereby affirm under, penalty of - perjury one of the following declarations:
),,,I hive And Will. maintain a certificate of consent to self -insure for workers'
compensation, mpensation, as provided for by Section 3700 of the Labor for the
performance of the work for which this permit is Issued.
I 'V i w6rkers"6ompensation Insurance as required by
. �, I have and will 'maintain I
S on 3700 of the Lab&.Code, for the performance of the work for which this
permit is Issued., My workers'. comps'n'saVoin Insurance carrier & policy no. are:,,,
Carries STATIPAIDPolicy No. 046=0-0403369
(This section need not be completed 0 the permit valuation Is for $100.00 or less).
O I certify that In the pirformance of the work for which this permit Is Issued,,
1 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 - shculd beco 61
subject to the workers' compensation provlsIons..9eCVpn 3700, r
Code, I shall fort hwith,6orfiply with those provisl
f?'Dite: Q -Z .'Applicant Oil
i -Warning: Failure to secure ., Workers,' bd"=V�wera;ge is _un1aWu_r`and-_
,,,shall Subject an employer, penalties and civil fines up to $100,000, in
'addition to the cost
6st of 6omoensatlon,ilimages as provided for 16 Section 3706-.
iof the Labor code, 16ter6st and attomey's fees.'
IMPORTANT, -A0 , plicIitlob is hi4bj made to the Directof of Building and Safety
fora 'permit subject 6,ilh6, conditions and restrictions set . forth -,on- his:'
application.
Each pers6h.upoh whos;15e'half this application,is made&'each person at
.whoreqti6it and foi'Whose b enefit Ark Is perfor'med under or pursuant to
any permit issued aist result of this ipplicaton agrees to, & shall, Indemn Ity..
4 hold, harmlessihi.City of La Qdlntaj� lts'offic6rs, agents and employees.
,2. Any, permit W686 as i result �of ihli application becomei null ind,vold If
'W&k'ls,n*0i C�m C niehb6d wlihWIIBO days from date of Issuance of such,
,00rmii,.orcesdbil6nbtw6rkior'i8ddijeW[Isubi6ctpormlttocincellation.,
I _CaAiiy.that 1-hve re6d,tliis'appilcailon-and state that the above'lnf6rmation Is
correct-)
dg(ebi'tdcompl'i Mth'all Clty;.arid,State laiws,relatlrig to the bulldlhg.
i- 4, orlstructioni,an I d Hereby aut.ho!rIz9representaflvqs of thisjC!ty to enter upon.
t0if abov6-mentlonid property forl 1 ecti U
!;8 ec" =W_ 44
��s' Innature (Owner/Agent) 1)8*11Z !,j
T
POT -,A ITMCT
JOB SrTEN'
ADDRESS
.6
Vt
OWNER.'
CONTRACTOR/DESIGNER/ENOINFER'
PG1K%V=M=FNUAL110)-ft1".a=
U1a"_0_8MD OE DIC fl
67-555 E=PAIMIAW 14
IA,QUIWP.
CXMRAL�= CA .92262
060)32s.9111 awt 4611
USE OF PERIVIrr
,R"001.r WITH
7_-.%Xf,-14-34f OAK44111 a it
V'"UAT1014 %946.00 LAI
181) coff OF COPMUMON -
2,946M
PERMW F= HUWARY
�" 830.110
m -41 8-M
=001? e j 01 000
MAY 0 9 2
WYOFILAQUINTA
FINMCEDE"
. 0
TOM 1?13=, I= DIM XQW,
RECEIPT sI
DATE
BY
DATE FIN
SPEC TQQ
A
L
INSPECTION RECORD
OPERATION
DATjE ` =
INSPECTOR
OPERATION
GATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
U Ducts
FOrtns dL F i
Duets
Slab Grade
Retwn Air
%*
Steel
Combustion Air
Rod Deck
Etfaust Fans
O.K to W . , t
FA.U.
F
Insulation
Vents
P.L
Grips
Fhpbw T.O.
Fans 3 Corrt►wls
Party Wap Insulation
Condensate LMes
Party Wap Finw all
Exterior Lath
ogad - Int, lath
Final
Fina
POOLS - SPAS
BLOCKWALL APPROVALS
Sim
Set Backs
Electric Bond
Footings
Main grain
Borrel Beam
Approval to Cover
EQuipmrtt Location
UndergrwjW Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
GasTest
Electric Final
Waste Lines
Heater Final
Water P
Plu Final
PkrmbbV Top Od
Ew Endowm
Shmw Parts
O.K. for Finish Plaster
Sewer Lateral
Pod Cover
Sewer Connection
Encapsu
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Nam (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Under CondLd
Rough Wiring
Low Vobp Wiring
Fbdures
Main Service
Sub Panda
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
U" Notice (Perm)