0205-104 (RR)UJ.
rn 4
°Z
U'Q '
z
Q-
X� WALL
mdyQ
U U
coY?
�..CJ 1
"'thereby affirm under penaltyof perjury that I am'licerised-under provisions of
Chapter 9 (commencing with Seciion,7000) of Division`3 of the Business and
Professionals Code, and my License_ Is in full force arid effect...
:. uceiise # } ;. J LLicc.. Class f' ' Eicp. Date
/
1�ate`"� Sig of Contractor
�,,+ " :OWNER -BUILDER D
Iihereby affirm under penaity of kury that I am_ exempt from the Contractors
LicenseLaw foF the following reason: .
I, ®W&," net, 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 roe r "
'( `) ; property, rty, am exclusively contracting with licensed
contractors to construct the project',(Sec.,,7044, Business & Professionals
Code). 3�+
O I am exempt 'under Section " to B&PC •forthisTeason
Date Slgnature'of Owner ri x't
{' WORKER'S COMPENSATION DECLARATION
I hereby affirm under` penalty of perjury- one,, of the following declarations:
( )� [have and°44111 maintains certificate of consent to self -insure for workers" '
;compensation, `as' provided for by. Section 3700 iof the Labor Code, for: the
performance of the work for which this. permit Is issued. ;
XI`liave and will maintain workers' compensation insurance, as required by
on 3700 of the Labor Code, for the performance of the'work for which this
'Permit is, Issued. My workers' compensation insurance. carrier & policy no. are: •
Center $%ANIa PollcyNo.'' f140-9�-03769
(This section deed not be completed If the permit valuation is for $100.00 or less).
( )>l certify. that In the performance of the work for which this permit is issued,
I shall not employ any person:6'any.manner so as to become,subject to the
`workers' compensation laws of California, and agree that if I''should beco
4ubject to the %4orkers .compensation provisions o e n 3700 WJar,
Code hII fort Ith comply with those provisi
Date Applicant s ,
Wang: Failure to. sec
rniure Workers Co "- verage i§ unlawful a
'Shall subject an err ployeir to criminal penaltles'and civil fines up to $100,000, in
addition to the Cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attomey's fees
IMPORTANT Appllcatio is Hereby made to the Director of Buildingand Safety
for a,permit,subject to the Conditions and restrictions set' forth on his ,
application
Each person upon whose behalf this'application•is made & each person at
whose request and for whose benefit work is performed under or.pursuant to
any Psrmh Issued as a result of.thls appllcaton agrees to, &`shall, indemnify
& hold'harmless the City of La Ciulnta, Its officers, agentsland employees.•
2. Any,peimit issued as4k result of this application becomes null and void if
work Is noi'com—Menced within 180 days from date of Issuance of such
pbrmit,'or cessation of work for"180 days will subject permit.to cancellation.
1 certify that I have read this application and state that the above Information. is `
.correct.,) agree to corriply with all City, and State laws relating to the building
construction, and.he�eby authorize representatives of thisity to.enter upon
t lobo"ve-mentioned `property for IWectlp ses
Signature (Owner/Agent) +r" Date `
3„
.W.� -7-BJUILDING�PERMIT� �.,.
' 0404
`VAWATION ... r SOT �° TRACt
DATE '` .
,
4
,�N
n
JOB SITE = ��� iyu r �y� �' i L
ADDRESS ..; ✓Qi�Al� . iri 4AX ' ° _
+ '
OWNER +. ,'; + f, -a`
CONTRACTOR /DESIGNER /ENGINEER
.•
PGRNTW&OW"r1TMM.0.M
D00CI%w-�✓w
PA SLK I Wf>'t1 � `:
67-5S3')r PAIM CAN%CENxi
L A (?rtJWA
6
C•}ATFI�Y.It�tL CITY' C:A���MdlT{922�2
V
t;760)3.2$ -9I A �� ` 461 1
,
USE OF PERMIT
Q�ERALgUIL�%INCi
,
R&RC7CJP' WIYH CLASS A MAT',XR1t I S* SLIM •
",
54-36h 3.4349 OAX HILL � - �
VALUATION Z94M0 L13,' .
'
5
F:STMATED COOT OF CDMiZt17C'I! OA
PERMUF E 9UMMARY
'
RU00F '. 101�000418 ' S30„00
°
• ` red _ `- J S. • - �
.� R : ;� .:P`
Y i »
�; f{ MAY ,u y
7
WYOFlAQUINTA
y If7NANCEDEPT. ,
t
fCOXIMUM09-
70M IPMM w
RECEIPT
DATE
BY
DATE FIN
SPE
INSPECTION RECORD
`OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
UWwWwroct Ducts
Forma & FootkW
Ducts
Shab Grade
Return Air
Steil
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
FA.U,
Framing
Compressor
Insulation
Vents
P.L.
Grills
Fireplace T.O.
Fans & Controls
Partywallroutatim -
Condensate Lines
Party Wal F'uewal
Exterior lath
Drywall - InL Lath
-'
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Hacks
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Under round PIbg. 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
COMMENTS:'
y
"A
`
h.�
<<.
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS%
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbduures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)