0205-103 (RR)eby
C iqa� 1,e,,pena of*oendeyftt'I'ani,:Iioeht,,ed:undt,'�p!ovisionsof
ho. ('ih Secfldn 7000) of DMsioiii 3 of the Busl�'ess and,
N'(0 'Protessionali Code, and my Licinse Is In full force dk effect. -
C-V,q, uc,nse
#
,CLIC Class - I;ECxp. D.,
a
te
VS114 3 ,V
0 .
6VAER-6811JALDER =37RA-HoN 7
W
ae Contractors
affirm.tinder penalty of perjury that I.am exempt from the,
CO)f 'r the following reason:
Z 1. asIQ
wh, 'ner' Of the property, o; my employees with wages as their sole;
compensatfdh;;Will -do the'work, and the structure is not Intended or offered for
sale, (Sec.,7044, Business 9 ProfessionalsCode).
1,, as owner of the,
'property, am exclusively contracting with licensed
odintractors. to construct the project (866. 7044, Business i Professionals
I "am' e'x'eTpt uhdeiv,Sedtlon B&RCAor this reason
C Date SIghature o -Owher.
of
WORKER"S.COMPENSATION DECLARATION
2 Zj�
OL a:' I hereby affirm 'un;er'pehaity perury one'of.the following declarations:'.
0
< I �have and Will mainialn a certificate of consent to self-iniur6 for workers',
X Lij LLcompensaItton, :
" as provided for 'by Section 3700 of the Labor Code, for the
0.-u �J performance of the work for which this permit is issued.
CD
-),I haviI,and Will mil'hta*in %�orkers!.6ompensauon Insurance; ai'required by',
4,on 3700 of the Labor CoI:16,,for the pertbrmanoe of the work fdr,which this
a'� Z' permft:ls issued. ,WLW6rk�rs'1,bor*nssVon insurance carrier & policy no. are:,.
Policy No.,
(this section -need
not be completed If the'permft valuation Is for $100.00 or less).
1 certify that In'ther performance of the 'work for which this permit Is Issued,
fshall h6t,employ ahy'perior! In any�manner so as to become subject to the
:omoen6atlonji 0
workers'�c we of Callfomla; and ag�ee that if I should be
1 0 �t"t .9 'bor
subjectio the w6rk6rs' c6iiiperigation provisions of Se 3 0 of;the
comply _% those !ii;oVIs
Code, f htylth
— h,04VI
mite. Annil
lvlfirrilng-"FaIlure to secure Workers' Cbo�ffonorfcoverage is uniawful'and
Shall 'subject an ernpI6yer,W criminal peniftids and civil fines up to $100,000, In
additiodto ihi cost of comi5ematl6h, damages as provided for in Section 3706
6f thilabbrodde, In'teteii and itt6tn6j'i fees.
IMPORTANT Application Is" hereby made tothe E)ir6dt6r of Building and Saf6ty
for lei _. piermk. Subject'to, - the,-Coi�dltl oni and; restrictions set forth on his
application.'
.1. Each Oers6n upon whose behalf this application Is made & each person at,
whose rsquest and for whosebenefit work Is performed under or pursuant to
any permit lisubd as a,resblf of thli aliplicaton agrees to, & shall, Indemnify
.,.& hold harmless th6l :city of La 06inti,Ats'officers, agents and employees.-,
2. Any permit Issued as a result of this applicitl6n.becomei null and void If
Work Isrno't-commenced wlihin 180,.days from'date of Issuance of such
.permit, orcessation of iWorR for,180 days will subjiat permit to cancellatlon...
ty
I certify that I hava4dd this application and state that the iboVe information Is
correct. i agree to comply.with all City, and State laws relating to the building'
construction, and hereby authorlze'repiresentaflvep of, thj§ City to enter upon
the sb6v'e:mentioned property.for InSpqPttion purpo0S-/,,
r itl
WILDINGTERMT.,
TMCT
•
JOB SITE 9 0AWJW4
ADDRESS
APNt
,,,
'k
OWNER 7
CONTRACTOR DESIGNER EN0INqFA 2
POA V= 10,11OUTM MMW%WW
PA 130xioK,
-555 F -CAWYOOMM
67 ASTPALtt
• JA QUOM
CA' 9222
q60025-9111.- mu# 4.611
USE OF PERMIT
(IM91KRAL DUIMD40 -
M1=FW1TJI CLASS A UAT1$aAL.3- OLDO. 54.491,,
/*
.4-409, -%117 OAKHIM- ',t
"NALUATION 60
s
]KISTUdATM CQSr aF CONUKUMON
2,946M,
PIRMU FEE 9[fARdARY
ROR00F.FU 101-000-418-000
4
MAY .0 9 i(101.
—.
WYOFLAQUINTA
FINMICEDEPT
t
X11 •T CONMUCTM AM PLMT CM=
130,00 -
L= FPOPAW
TomplampmVICIENOW
RECEIPTBY
1:
J
?FINA
. .
CMR
.
INSPECTION RECORD
OPERATION -
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducks
Form & Foo&W
Ducts
Slab Craft
Return Air
Steel
Combuz.,em Air
Roof Dec*
Exhaust Fans
O.K to Wmp
FAU.
Fm"
Compressor
,
ulation
veft
_.mplam P.L
Grills
.46place T.O.
Fans & Controls
_Pwty Wall Ins"on
Condensate Unes
Party Wall Firewall
Exterior Lath
Drywall - K Lath
Final
FlnW
POOLS -SPAS
BLOCKWALL APPROVAL t—'
Steel
Set Backs
Electric Bond
FoWW
Main Drain
Bond Beam
AWovat to Cow
Equipy*xd Location
Underground Electric
Underground Pbg. Test
Final
cft Pipft
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Unes
Heater Final
Water Pk"
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Paris
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Pq"
Ga Test
Appliances
Final
COMMENTS:
Final
UfiWy Notice (Gm)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough WirkV
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.J.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)