0205-069 (RR)w"%,LMnAiJUIH
ner pe .-
I hereby. affirm under penalty of perjury that I am Nceried under: provisiorta of
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- BUILDING"PERMI��� .�
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Chapter 9•(comm&r ing with Section .7000) of DIVWori 3 of,ttie Business and
force and
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Professionals Code, and my Llcahsa Is In full effect.vALtlAT1bN
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License x W. ( ° Exp. [3i1te
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Ste Signature of
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CONTRACTOR /DESIGNER / INEER
Contra0tor
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01fUNER•BUILDE NAVMr
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f I hereby affirm under penalty of perjury that I errt exempt from the Contractor's
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`67�353 F.W PJU,d�d C.�AWON D101
,License Law for the following reason:
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CATIJEDRALC�7Y CA, X62 '
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(') I i; as owner of the property, or my employees with wages as their sole -
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compensation, wlll,do the work, and the structure is riot intended or offered for
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sale (Sec 7044, Business & Professlonals Code). ' ' ° • W
USE OF PERMIT t
( ) > 1; as owner of the. property, am. exclusively contracting with'licensed
GINUALBUMMIll I
contractors to construct`the proJect�(Sec. 7044, Business &.Professionalsc, ;
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O 1 am exempts aider Sectiiyn a for this reason, d o
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Date - Signature of Owner r -
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WORKER'S COMPENSATION: DECLARATION
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I hereby.'afflem under, penalty of perjury•one of the following, declarations:
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O 1 have and wilt malntain`a certificate of consent to self-Insure for workers'
v�►LilNIM 2,90.00 La ..
X' W U--*,compensation,
as proJided for :by: Section 3700 'of the`Laboe .Code, for, the
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performance of work for which this permlt is Issued
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I have and will maintain wg,"' rs''compensation ;insurance, as required by
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Section 3700 of the Labor,Code; for tiie.performance of the work for which this
Issued.
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permit'is My workers' compensation Insurance carrier & policy no. are:.
Center •. A � �• Policy No.. Qf6.9?'•� XW,20
, , 1ob"nMAT EI COW OF C(l:l'a�!'LRUCOON
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ItMff INUWARY
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(This section need riot be completed ifRhe permlt valuation is for $100.00 or less)..
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);I certify that imthe performance of the work for which this peienit is Issued,
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I'shall not em to any'on In an manner so as to become subject to the.
workers' cc pensation.laws of Callforrtia,,and agree that If I should become
aubj@ct to, the work�rs' Compensetion`provislons of Secti�7Oe Labor
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Code, I shall forth'th comply with thos ns.
fSate:c_•Applicant.
n-coverage is unlawful:and.
,Warning: Failu s to secvf Wortcers' L=hid%1vil
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f" i )''� �!J10L
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shallsubject an employ -Fto cn l•~ e fines up.tO $100,000, ih .
addition to the cost ofoompensation, damages as provided for In Section 3708
WQUINTA
of the Labor Code, Interest and attorrisey s fees.• ,- `'`
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FINANCEDEPT
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11 PORTANT, Application Is hereby made to the Director of Building and Safety
for a permit subt td, the conditions and "restrictions set forth' on', his
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applicMich.r-
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1: Each person upoh whose behalf this application Is made & each person atU9,T(Xil
. rwhose request and for whose`benetit work Is* performed under orpursuant to -
A PLAN C!BC`�5AhOiQ
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any permit Issued as a result of this applicaton agrees to, & Shall,;iridemnify;
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& hold harmless,the City of La Quints, Its officers, agents and employees.
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• 2. Any permit Issued as a result of this application becomes null and void If .
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work Is not. commenced within 180 days from' date of Issuance of such
a
permit; or cessation of work for 180 days will subject permit to cancellation.
I,certliy that I have read this application and state that the above information is
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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
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t above-mentioned property for igpec n purposes
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,Si(Owner/Agent) ^' Dates `
RECEIPT
DATE
BY
DAA FINAL D Q w
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I PECT i}
- INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
set sacim
Underground Duct*
me
Fa & F
Ducts
c
,
Slab Grade
Return Air
<t ,:
4
Steel A
Combustion Air
Roof DeckExhaust
Af
Fans
w•
O.K to Wrap
F.A.U.
{:
,
Fraining
C
Insulation
Vents
Fireplace P.L
Grills
Fireplace T.O.
Fans 8 Cautrals
Party Wad Inwitation
Condensate Unes
Party Wad Firewan
Extedor lath
Int Uth
7 =77777
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Finali.
.- .
Final '
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
Set Backs
Electric Ban
Footings
Main Drain
w
Bond Beam
Approval to Cover
-:- ,
E Location,
Underground Electric
U round P". Teat
FbW
Gas 130m
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater F'uual
Water Piping
Pkimbing Final
PkunbbV Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
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Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Condult
Rough taking
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Penn)
COMMENTS:
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