0205-099 (RR)I, hefeby affirm under penalty of perjurythat -I am -licensed under provisions of
Chapter 9 (commencingwith Section 7600) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
,."Date I Signature of Contractor
/.1.
OWNEWBUILDER DECLARATION
I hereby affirm under -penalty of perjury that'Jim exempt from the Contractor's
License Law for the following reason:
1, as :owner 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 & Profess&A Code).
1, as owner of the property, am exclusively contracting with licensed
,contractors -to construct the project, (Seca 7044,* Business &,Professionals
Code)-',",.
O Viimexiiimpt under,Section B&P.C. for this reason
Date Sig,hature of Owner
WORKER!S-COMPIEkSAil'ON'-DECLA,RATION
I :hereby affirm 6 n8e r.'p.6 n a I ty, of , pe rj u ry one of th e -fo 1160 n 6 declarations:
O k6vel and 4illmaintain a Certificate of Consent to self -insure for workers'
compensa ion_ -pr6vided for by Section 37o6,, of the Labor Code; for the
, " -47 h - i �; 'this
. h -4 11 1 issued ' ' .
performance o I e Work for which t is permit is Issued.. .1, " ', ' '
_;01 maintain workers' 6�perisatio�.insurance, as�re
(*171 have and quired�by.
'S, ection- 3700 of the", , bbr�',Code, 6'r th—e..p,;r(o-rin'a6cL-6f.'the; work for wfiicK'this
permit.,JS Jssued. ywprkem''compensation insurance *carner,& policy no. are:
. yry. ..Policy No,
(This section need not, be completed if' the 0,6kii valuation is for $10 - 0 00 or ,l S).
1�certify
. th,at in the'p',erformanc.i-oiithe
w. oIdOor
whi6h this"permit is,-issu. ed,
-,_
1shall not employ anyperson,in any manner,soaSto-become subject to the
workers' -compensation laysof California, aAd'agree that if 1sh6uld become
,subject -to the'work"rs 66npe66ati6n Drovision6,of
SectioA 3706 of the. Labor
rihall forthwith comply witff those provisions', - XV
,DateAppIicant
Wbrining: Failur;e to secure WorkersCompe�iafi . 6'fil/ erage-is unlawful and
, : 'criminal'
- .. 1. , Cir, *Pl _. I . $100,000, *,
ZShal1l'S6'bj,Erct,.an ei'mployer.-to criminal * pehaltiei. and. c, i�'a nes' up to in,
addition, t6 thd_.coiii Of compensation, dimages as provided
cled f6r in, - Section 3706
-.of the Labor. Code,, i M46611. and. 6tt6rney!s ees. sr
,.,..Imp,QRTANT_,App,!ic4tion.,is_hereby,Mp�iq tq-the - pirector of Butiloing,andSafety.
for a permit ,subject t6 the.-cDnditibns� 'and restrictions 'set forth oh his
application.
1. Each person upon whose behalf this a"41icatio'nIs - made & each person at
pp
whose request.and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, &'shall, indemnify
& hold hiarmless the City of Ea Quinta, its officers, agents and employees.
2. Any permit issued.as a.result of this application becomes null and void if
:work' :is not commenced within 180 days from date of issuance of such
permit, or cessation of work 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 State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for. inspection purposes.
Signature (Owner/Agent)
Date •—)
PERMIT #
BUILDING PERMIT
DATE LOT TRACT
.14ALuAT16N
JOB SITE
ADDRESS
'8LJ.XV' ;S OAK 033,;.i
APN
OWNER
CONTRACTOR I DESIGNER EN (NEER
.1110A 1VIOST RERM(SN11M, Iff-W.F.OWNFPS
41-J"n": TIII' T >A-0. F4111JET.1) OF(Wll MIA, IW(',.
P.O. YXXX )(360
EAE;TYALM CAJAON 1,1110VE
LA (7(ANTA
L 'i'V f,.1;k 91])611,
USE OF PERMIT
PKIM14111 IFY It, 1,;V PANKRY
Sl!,93 !(.M
tSN' 11W-PA10 felt'.A�:8'
t) till
'AL
1V
0' (,� NONV
1 — W
Of
............
�RECEIPT
DATE--
BY
DATE F1
3ROM9
IN
S, WCO
OPERATION
DATE —� INSPECTOR i OPERATION ATION
SrPC 0
BUILDING APS R' VALE
WCL; ANICAk��►:�:�':�L
Set Backs
I
; Underar; and Ducts
Forms & Footings
—
; Ducts
�r
Slab Grade �^
Re urn Air
Steel
Roof Deck
! Comcust{or, Air
F must 'raps
0. K. to Wrap
I i
—
A.D.
Framing
j
! Compress„-
I I'
Insulation
- t -
Vents
Fireplace F.L.
!
i Grills
F repiace T.G.
Fasts & Controls
i I
-any W --all Insulation
� Condensate Lines
I
— —
I Warty Wall Firerr!I
�
cyterior Lath
--
Drywall - int. Lata
Final
�+..
POOLS
I---
JL:a�•stLYY�1S � fit` t`r'2�'1�f���
� --
-------
-
I steel
Se: Backs
--=---�
-
c.,evtr;c Bond
, — —
f Footincs
rBon:' Beamf
f j
j
�� K13in Drain
--��.,-�rc,•al is
Unca;cround 4iectnc
UnLlerr.;c, ndP! q. ,est
�
I _—_
PLrJ°r' eNG APPROVALS
-� Gas es,
— �-----
I E:actric F; tai
VVaste Li.^•es
t 4�f_ei ipno--
Plumi?ing Top OLP
� er Pans
F—seraer Lateral
iGas Piping—
I as Test
—_� i
� —_ — -
'----- —
_—•r�_—___..
...,._......_.._....._.�__..—....
—.�_.�.
_ _`.—i ��_._.—_.-
_–.—_{ ry.e+ •w.•�: t'' S p i 4.. f �' f Vii.
Fi
ELECTRICAL RICAN. APF'ROVALS
;
Vie.;,p. Power Pole
'-�nferground Conduit
_
i
{
ttyph Wiring
P'{ � ii
i Low Voltage Wiring
�
Fixtures
!
I
Main Sere: a
---
{
Sub Panels
Exterior Receptacles
-6-- ---- — f —
�
—
Smoke Detectors
I Temp. Use of Power
Fietat -..—
i
Utility Notice (Perm)