0203-098 (BLCK)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 _ Fjcpj Opie_/
a
191 �. �.- s13
/ Signature of Contract( !`
J
OWNER -BUILDER DECIIARATION
I hereby affirm under penalty of perjury thiat 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. 704.4,.. 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 issued. My workers' compensation insurance carrier & policy no. are:
Carrier STATE FOND Policy No. IN1391•01
(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 bec2Ae subject to the
workers' compensation laws of California � agre tNA if I should become
subject too the workers' compensation Jd"i ill S c i n 3700 of the Lam
Code, I sha�I & W. Ilh�comply with th seep • vl to
-.,Date: Applicant f
Warning: Failure to secure WorkersVCompensation 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 persoh'af,-:
whose request and for whose benefit work is performed under or ursuant 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 Ci y, and State �ws relating to the building
construction, and hereby authorize CJ
ofrthis City to enter upon
the above-mentioned property fo/��i��s�p°Cctrn��urposes.
Signature (Owner/Agent) �rFf''%'`•r ' " rf�''r�fDate
BUILDING PERMIT PERM T#
DATE '' / VALUAINLOT 024 TRACT
WWI=
JOB SITE APN
.6DDRESS 47- V14 ANTME' S -
OWNER CONTRACTOR / DESIGNER / ENGINEER
17460 H 17'Ii ST. -0.106 178480 Y 17" 1 WE 0106
CA 92790 a°iF8`I'iN CA 9270
(714)508.4440 M0. 4465
USE OF PERMIT
,w,03,1a. 6' &44 L.F4' UARDEN Wt1L14 ORC O SYSTEM
6VT, WALL 85.00 LF
4 RT. WALL 44,Q0 LI
r C Ai `l l ti4 `i 1t�A7 HER 101-000-418-000 SM
a.,
\/81_$8 -TOTAL COM I-RUCTION`Mlf►���yylg��I...�:pp@���` ..�Fyy 101CC pp;+�� Icy :$�°(.4.C^^)0A
�ECEIPT DATE/ � � -'�� I,Bf DATE FIyA (EDD 2 " 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 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
_ �p a ZZ 25 7
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
• D 3 S
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
-ewer Lateral
Pool Cover
Sewer Connection
Encapsulation
eGas 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:
r
LOT ,x m
BLvu^ -
�x1 • �^ � /; R=24.50'
L=37.37' 777'
/ A=123649"
—� T=271'
R=918.50'.
- L=86.67''.
A=0500 56
T=40. J6' —
CI�
OF � (�UINTA o� r��,
3utIN&SAFETY ® T•
ROV i
NSTRUCTION-
oPROFESS/pv,./LST�'s is d:G�
C FARti F ®A -OZ BY /c
No. 31653 i
Exp. 12/31/2004
�CIV11.
v/03 A SCALE.- 1"=20'.'
47-225 VIA ANTIBES
LAKE -LA OUIN TA, LA OUIN TA, CA 92253