9906-013 (PLBG)_ r �
LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions.of
Che; ter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
S5I 5 A .f3
d' tfti>7
�r`
Date � Signature of Contractor ,' � *'a -�����•�'~•"
OWN ER-BUILDER,DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( .) ' 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 Signature of Owner
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
Section 3700 of the Labor Code, for the performance of the work for which this
permit is;(ssued; (vlyjtworkers' compensation insurance carrier,t8�t:policy no. are:
Carrier 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: Applicant
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
:I onstliiction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
.,
Signature (Owned,4gent)' `� ! � - ^" Date 4�6
i z
BUILDING PERMIT PERMIT# CONTROL#
t,.►>�
3443
DATE .l 4 VALUATION #7� LOT TRACT
JOB SITE APN
ADDRESS 73-005 SAN T1AI0'iTL0 44&'id4i- 0Z
OWNER _ CONTRACTOR / DESIGNER / ENGINEER
10AV LANC1.•Uft10 TRT SCAR C0 3.1' PWC" ON
78005 ::Aa`t'1MO'{"E0 M' _V150 CANDJ..isWOOD M7
LA QUINTA CA 92253 CATHEDRAL CITY CA 92234
lfiC-AT.4
USE OF PERMIT
a
Pi..l.11ki3�f l'•Ii.i " -
NEV '.l" 'A01F NT ONLY
1,'1(X).00 Ls
. E,811MA 1 ED CONT T` OF CONSTRUCTION
i.,immaiNia mi -• ski rtR 1101.000-4119.000 S?(1.9p
3,700.l4(i
SQB-10TAL CONSTRUCI'Tf k AND PLAN CHECK I, $30.00
LESS 1'RU-PAW IIE13S $0.00
AT, PE10'1 FE,.Es-911iN:NOW
J .JUJU 0.�.1Z 'I
By
J° �.
RECEIPT DATE I Do 1IrI_E4q � / 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
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
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
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
• ` ^( - .t ,� ' i ..'.n":'^"�"' �'-. , � .... _ X15; R.A'C.cew,.. , ' ,
TV
.'OF LA U"Ul IM
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t.. �R..t�NSTRU
SUBJECT T _
® INSTALLATION AS P R�
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+ : ANDALL-AP LICABLE
CODES).
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COUNTY bF NVM81b5 HEALtH SC-nVICES AIGENCY
bEPARTMENT OF ENVIRONMENTAL HEALTH
P(sodySewage Disposal
Trailer Parka LKISi .Gal. Septic Tank (17s"0 6-40[n &VA611) u
Motel, Apt., Hotel. Sq. Ft. of Leach line
Dwelling �iClST.�aBa�.,> � %-No. Dia_ i1 BI - 43 TD -4 SID Seepage Pk
Commercial Building / Connection to Sewer wmk E,071.Yt�
.. Swimming Pool Connect to Existing S.S.D.S.
-&200 ori -site regenerating water softening devices may be discharged into the individual sewage disposal
system herewith approved without clearance from the Water Quality. Control Board.
Water supply servin h's insg ation must be from an approved source E)0-7-- (C (/wj,q)
All sewage dispos ninstal�aiion must conform with requirements of current Uniform Plumbing Cods.
Any cutting, gradin /I or filling in excess of two(2) feet will nullify sewage disposal approval.
Approval has been obtained from the Regional Water Quality Control Board for installation of the sewage
disposal system.
This Is to certify that the Riverside County Environmental Health Services approves the subsurface sewage
disposal plot plan to obtain building permit for 'nstallation, constr7i4.n..DA+E 6 - f - 96BY
I
MAINTAIN 1 EXPANWON AREA. MIN. / FRO ''I ANY 7� &ew
MIN. 10' FROM ANY WNGE TREE OR WATER MAIN. - v -ft -i
II F, n r. 64/zL.liE'o / �� !i /
ANTMA-MANTED
DEPARTMENT OF PUBLIC HEALT -A Of tbM >afRM by t2w Deparun,= ag reaW
IS VALID FOR ONE (1) YEAR MWth of Riverside County does not relieve the Sb
h•
FROM DATE OF APPROVAL 0" or Arehfteet °f the reWwibilitY for the dna
v or Arehiteetural deafen."
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