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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions, 6f
Chapter 9 (commencing with Section 7000) of Division 3 of the Business*and-
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Professionals Code, and my License is in full force and effect.
Licenser# 4 Licc.y�Class Exp. Date p'
T5 FaC; O2128/V
Date Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
(,)e) I; 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 & Professionals Code).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
( ) I am exempt under Section , B&P.C.,,for this reason
Date P�
'}... Signature of Owner '� r'��rt ;� a�:sf....-•
WORKER'S COMPENSATION DECLARATION
I. hereby affirm under penalty of perjury one of the following declarations:
( ) I have and will maintain a certificate of consent to self -insure for workers'
compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
( ,) I have and will maintain workers' compensation insurance, as required by
S(;&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:.
Carrier ZT,&T& n NLXFv ) Policy No.
(This section need not be completed if 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 any person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date: ? a>, e r,. Applicant. 1 . �''
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Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties 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 attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. 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 applicaton agrees to, & shall, indemnify
& hold harmless the City of La 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, insfec4on2rposes.
Signature (Owner/Agent) DateL(,-
+BUILDING PERMIT PERMIT40
0.210-304
DATE I()/14€F'"'K..0 VALUATION SU22 LOT TRACT
JOB SITE
ADDRESS 46-374) C.A=() P.4LJAS DrdVj,I:'
APN
OWNER
CONTRACTOR/DESIGNER/EN (NEER
5.370 a;. KWO PA1.10 M,
74318 VEME WM -TTF. 12
S,A.QT' , WT'A CA, 92253
R.°tt.dar9.l:t.I1TFrer CA 92255
X411 CMD -4 2934
USE OF PERMIT
ORNTrt2 L MLIM40
",1 3,,1? 6* O OCK'W LUI65 LF S" B1,04"K, VIAIA.-ORCO STANA DAR113 PFX
APPisWED FILM VERBAL, OK BY STAN 4AWA N! CMD,
k ,h"T. WAU. 901(to Lt?
3 rr. WAIT. 165.00 L 0
XMWATED S (3n." 01F CONNMITI=00
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Cnr:'N00TRUCTION FE1.11
OCT 3 o 7U0[
CITY OF LA QUINTA
FINANCE DEPT.
_
• .1..td.+tIJs P..I .r"'.L'ICS,M1D3.I, ITIMS
S0100
RECEIPT
DATE r
BY .,r
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
-,Set Backs r
ifootings l t
Electric Bond
Main Drain
Bond BV7
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final / _ -�-2�
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
r. Waste Lines
Heater Final
Water Piping
I 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
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fudures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
NOTICE; THIS IS NOT A BUILDING PERMIT
APPLICATION TO CONSTRUCT
DEPARTMENT OF BUILDING AND SAFETY
COUNTY OF RIVERSIDE
DISTRICT
Permit No
284 199A 9/74 CANARY—FILE, PINK—APPLICANT
Owner A hitect---_. Contractor__. _
Addres en— jglm7Q� ress___ Address —._—
City City_-- City__—_ --- —
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Phone�„ Phone _ Phone— _--_—.—. _
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I (we) the undersigned, hereby certify and acknowledge that I (we) have read the application and agree that if Curb and Gutter, and
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Paving, and/or Dedication of right of way is required by the County of Riverside, the Riverside County Department of Building and Safety
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shall not make a Final Inspection until said requirements have been met. I am also aware that no work is to be done within the County R/W
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without an encroachment permit.
NOW, therefore, it is agreed that I (we) will not occupy said property and will not cause said property to be occupied until I we) have
complied with all laws of the County of Riverside and the State of California governing said property, r
F4?dl_�
DATE —lL� SIGNATURE OF OWNER AND/OR AGENT — —
Approval by Signature from the Following Departments Listed Below
Must Be Obtained Prior to the Issuing of a Construction Pervnit.
I SPACE NO.:
1 USE OF STRUCTURE
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JOB ADDRESS C��—/Q
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�p SINGLE FAMILY DUPLEX D
LEG D SCRIPTION OF P-ROPERTY Zi `�y
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oZ�i 3 — APARTMENTS AGRIC.
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--'~--'— COMMERCIAL INDUSTRIAL
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COMMUNITY ' ALTERATIONS ❑
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NO. OF SUBMITTED PLANS — USE OF PERMIT _
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CASE NO. e
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NO. OF P IRKING SPACES REQUIRED _ NO. OF BUILDINGS NOW EXISTING
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ZON ETBACKS: FRONT SIDE REAR
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GRADING PERMIT REQUIRED? YES ❑ NO ❑ LOT SIZE
SETBACK ORDINANCE # OF FEET REQUIRED ON STREET
DATE �r� SIGNATURE OF LAND USE OFFICI --
DEDICATION REQUIRED: YES ❑ NO ❑ NO. OF FEET___.
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CURB AND GUTTER REQUIRED: YES ❑ NO ❑ STREET
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CAN CURB AND GUTTER FEASIBLY BE INSTALLED? YES ❑ NO ❑
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HAS AN ACCEPTABLE APPLICATION BEEN MADE FOR ENCROACHMENT PERMIT FOR DRIVEWAY AND STREET
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IMPROVEMENT? YES ❑ NO ❑
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DATE SIGNATURE OF ROAD DEPT. OFFICIAI
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SWIMMING POOLS PUBLIC
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SEWAGE DISPOSAL
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FOOD ESTABLISHMENT
WATER POLLUTION REMARKS
FLOOD CONTROL
ae w AIR POLLUTION
_ DIV OF HWY
o — YOUR PROPERTY MAY BE SUBJECT TO
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FLOOD. RIVERSIDE COUNTY ASSUMES
NO RESPONSIBILITY IN EVENT OF FLOOD.
284 199A 9/74 CANARY—FILE, PINK—APPLICANT