0206-168 (PLBG)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 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
r, 4192180 x:21042
q k i1sCTt'2t
Date "-26"3) Signature of Contractorjn t , VXjJ'Jr
/
OWNER -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 Sianature 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.
^�e) 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 issued. My workers' compensation insurance carrier & policy no. are:
Carver VIRGINIA SORXTY C Policy No. I050+VOOT"rt9
(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.
Dater- •� r- *' 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
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
N
Signature (Owner/Agent) s %%�� Date ��
BUILDING PERMIT PERMIT#
DATE 06,7020,' VALUATION S.41AX)OX0 LOT MM -1. fad -TRACT
JOB SITE
ADDRESS 8-171 RAN'I2A+1,(MO t, APN
OWNER CONTRACTOR / DESIGNER / EN INEER
A1..MAOUNGS .dALMS1 MR)URGIt.OUND CONST.
78.171 RAN TI dME0 Sri' :48103 VI;J'3.'ADIUVE
LA. QVIIN A CA 922 CATRE?t?£uA.i. MY CA, 92234
(760)324-1911 X141' 769
USE OF PERMIT
NKV SL, 21NA E PIT 011i,Y PL?R COUNTY flEAI,TH L),I,?IIT :P PP&OV W VLANa.
VALUATION
ION
V00,00 Li
x,gnw.X'ED C09P OF CONSTLX1"iTMON
PRAW11 rn" Mmmulty
tJ�UN2 U 2002
CI`TYOFLAQUINTA
RNANCEDEPT.
SUB -TOTAL
F TMS PFS -PAID MRS
TMAL FXTWFrJM8 DUE ADW
RECEIPT DATE �4G I BY D T NALEOD�INSPECTOR
e' - 7„ /
fit;f
$37,50
$0.00
t47.50
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer 1 1—.7-15,
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas) -
I ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
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ASSESSOR'S MAP BK. 6/7 FO. 33
-RIVERSIDE COUffrY, CALIF,—
ry CITY OF LA' QUINTA
BUILDING & SAFETY DEPT.
APPROVED
FOR CONSTRUCTION7,
UNITY OF RIV
DATEU�-MRTMENT Q
HEALTH SERVICES AGENCY
IVIROh.MENTAL HEALTH
X
t -cod _._1 Sewage Disposal ? p,. (�/EL0 V�/�Y
Trailer Park rte/ ST. ,Septic Tank (._, 64-�� CT ti=Mr+f�� l S / ZE Di
Me Apt.; Hotel. �pyu.) _ Sc. Ft. of Leach �ine
I� n$ 6#'S T , ( Mak/ �} DD _ _ j— rvo, 6 / Dia��61'� 3 TD � MD Seepage Pit
Comrti'`ercia! Suiiding ..)c:ction to Sewer
Swimming Pool Connect to Existing S.S.D.S.
X No on-site regenerating water softening devr,,A,�_i:„ discharged into the individual sewage disposal
system herewith approved without ch:.;;a; ::., ?n , VValer ealAy Control Bo4rd.
Water supply servin� jhis i stallat:on ;nus: ; a�:' appro ecr rce k �x lyr (r, Urti� J
AN sewage dtspos�dt"ifigt'i#'ti✓ci must : ar::;r:�, 4itt a*� �. /irem:,nts of currentllniform Prumbing Code.
Any cutting, gradi4o" r filling to c�xco:ys a; ie?o 2j tw=:; v'41 nullify sewage disposal approval.
,/Approval has been obtainod from the Regional Water Quality Control Board for installation of the sewage
¢isposej system.
This is to certify that the Riverside County Environmental Health Serv• approves the subsurface sewage
Jispoeal plot plan to obtain building permit for • taa0wion, construct' f !/
`)AT>_ BY
MAINTAIN 100% S(FANSION AA%::..MIN. /,TO FRf^%Ikfi ANY yVEIA 7'o
>d W 10' FROM ANY TREE 09 WNATER MAW c , �%J!v
/( p / / � t • r:��Q�C..I:e�/ �!CL'�...""�-,L%.�/ltZ.o��tY7"t-�ltl
TY1114 A1&,J
3,
L
FFROW,
;� � �reval of these piano by tae Department or itscrg;y jl JHMIth of Riverside County does not relieve the Engin.
s,!E 1 OF 1�'�' �[a1 *a or Arcbltect of the responsibility for the F rWaa,
D FOR 011 EAL lot or Amhit�esturd deeizm,,
ATE Of APPRO ) YEAR
_. j
t.. 4; S.. :s� a r. '�'r •,.'�n,. •.''.a `..
it
`4', LA QUINTA' ;
iv ray' &: SAFETY DEPT.
P' R CSV E D �' �U1vDERGROUND ;CONSTRUCTION
FQF,�
J f Y'� 38703 VISTA DRWEi
• �.. '
CATIEDRAL,'CITY ` CA. '92234' • ' t
(�1,,7 �-i �- 760)324-1911; FAX (•760)324-9541 '
CA.LIC.#4821.80, ,
7317/
WA V�fl
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