0205-103 (RR)'N hereby affirtirunder penalty of pedury,thdt 1 am licensed undeY provision -s of'�'
1-. Chapter 9 (commencing with Section 71)00) of'WIS' lon 3 of.the Business and
,P,. rofessionals codejodmyLlceynse Is in full force anis effect.:
fp` .{�Ly °;FLlcense# �.. " ` •uc.Class Eicp.Date
if` wF.• 3 r I
W114V
i
lit' i� i r tee 9 J,L slgnatureyof Contract` �'
O�dr OWNEA-BUILDER DEC R ON
J U; r ..
W W -r` `1 hereb''a iunder penalty of, perjury that I am exempt from the Contractor's
— `� • . License ` for ttie following reason: .
(i Z ; ( ) I;�as quriti�ier,of the property, or mytemployees with wages as their sole
t "Compeneatbn,`wIll do the work, and the structure is n_ ot•intended or offered for
} - "sale (Sec 7044, Business & Professionals Code).
( .)} I, as owner of,the property, am exclusively contracting with licensed,
contractors .to construct. the project (Sec. 7044, Business & Professionals
O' I am exempt,underBection... -'ti, B&P.C. for this reason
1Vw Date �5 ` ` •8lgnature of Owner
6 cq
I.
a Q� 'WORKER'S COMPENSATION DECLARATION
`prQ,� I: hereby affirM under penalty of perjury one of .the following declarations:
1 have and will maintain a certificate of consent to self -insure for workers'
X W;O compensatlon, as, provided for by Section 3700F6f the Labor,Code, for the '
0, J; d pe''rmance of,the work for which thls permit is issued. `
Q 0 " ) I have and will' maintain workers' compensation insurance, as required by
I
tj V Q le�on 3700 of the. Labor Code, for the performance of the work -for. which this
hermit is Issued My workers' compensation insurarioe,:carder & policy no. are:
Cartler`�1, iiD Policy No.-`6.0QDOl�09
V' _ ., '
r (Thlssection need not be completed ii the permit valuation is for $100.00 or less).
)-''I certify that in the^ performance of,the work for which this permit is Issued,
I shall not employ ariy'person,16 any rnanner so as'.to become subject to the
-workers' compensation laws of California, and agree tfiat,if.l should becofne
subject to the workers' compensation provislons Qf Se ion 3 0 ofithe bor
f ,Code, al fo hA Ith comply with thoseprovis i
i Date " '� Applicant "L
a • .,,,Warning: Faliur' to secure Workers' Co o coverage.IS unlawful and
-u shall subject an employet to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, bamages as provided for in Section 3706
' of the Latior Code, interest and ettomey's.fees' Y
IMPORTANT Application is hereby made to the Director of Building and Safety
' for •a permit aubjsct to the conditions and restrictions seti-forth on his
application
q �� 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 permit issued as a result of this applicator agrees to, & shall, Indemnity "
'khold harmless the.City of ,La•Qulnta, its officers, agents and employees.
2. Any permit issued as a,result of this application' becomes null and void if
work' 1s not commenced within 180 days from'date of • Issuance of such
pe,milt,'orce"ssatlon of'wo'rk 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 Statet
tlaws relating to the building
construction, and hereby authorize representatives of to City to enter upon
the above mentioned property for'Inspe . ion purpo es.
} mi k;!, Signature (Owner/Agent) j
76 71V
r` dJ
UILDIWPERMIT.%, ry "
" - 621 lica'-1
DATE L ✓`�;� VALUATION Qy , !bt a r� " TfiACTr r t
ek
JOBSITE
ADDRRESES S
�'T �
~'
h' s'.4 f ....
r.:• .
OWNER • T " r'
•
CONTRACTOR / DESIGNER / EN (NEER
,1. GAV=t •N1w
POO. BOX•1060� • r
67.554 AWPACM CANY014DA
A
l[,A r2;
` C A�"MDPAL Cx Y CA 92262
(-1603225-9131 ' OBW 4611,
USE OF PERMIT
MR001F.'WITU CLASS A VAY'iEdtLALS?' ELM 54.4210 '
$4-4K $1.397 OAK HIL6
YA+Lp TION 4418,00 !,B•
x 'iN�ATim) cost OF CC,tASTRUCT1o"
/�i/�� `k�y'
iiMM
�
rREROOF F) 1 q1 �Ot 418-t7� a,39,OD '
r
MAY u 2001
,
WYOFLAQUINTA
FlNANCEDEPTw
I T01'�t,,.CON IJCT ?' Am CHRM
~ 163A�t3t�
,M _
IMAL MUM'F= DUE nOW
RECEIPT
DAJEy
>
BY'
DA�FIN/�
3 ��
I ECTOR
r
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
-MECHANICAL APPROVALS
Set Backs
U round Duds
Forms & Foot^vs
Duds
Sfffi Grade
Return Air
Steel
Combustion Air
Roof Dock
Exhaust Fans
O.K to Wrap
FA.U.
FrainkV
Compressor
Insulation
Vents
Fireplace P.L
Grills
T.O.
Fans &Controls
Party Wap Insulation
Condensate Unes
Party Wap Firewall
Exterior Lath
Dr
pall - K Lath
Final
Final i
POOLS - SPAS
BLOCKWALL APPROVAL
Steel
Set Backs
Electric Bond
Footings
ain Drain
Bond Beam
pproval to Cover
rEquipmnt
Locationnder
round Electric
nder round PI . Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Uncs
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:
`
"
i
'' >
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit.
Rough Wiring
Low Voltage Wking
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.J.
Smoke Detectors
Temp. Use of Power
Final
WAty Notice (Perm)