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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)