0203-097 (BLCK)LICENSED CONTRACTOR DECLARATION
I hereby attirrfi under penalty of perjury that I am Iid6hg6d under prd'vi§idhs dt
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._ ate
Date J%_ - Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury thatJim 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
Semti,
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
Policy No.
�?T.�.s�9�rl1�D '1fs4139!-dtI
(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 su9ject to the
workers' compensation laws of California, and a r e th't if I h�oYiId become
subject to the workers' compensation provIS`1 df a tiofi 0 of the Labor
, i.
Code, I•steal fo hw't�i cJ�mply with thosfe�p vlslons.
Date:rr�`r/�pplicant f
fv 4-1
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal p nalties and civil fines up to $100,000, in
I
ddition to the cost of compensati(DW, 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, indert)nify
& 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 carfc.ellatiori:-
I certify that I have read this application and state that the above informafibn is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of his City to, enter upon
the above-mentioned property forms ect, n/p rpo's 5
Signature (Owner/Agent) //� //�°=`�""Date--�/�
,,K DING PERMIT . P RMITN
DATE VALUATION LOTd� % TRACT
f
JOB SITE ,- "
APN
ADDRESS ,t 11 Fly y A tY f7a Y��
^9l-•d�,1iv3 �/i�.514'�I ,i,¢3"'�:R�1.Y
_
OWNERp
CONTRACTOR/DESIGNER/EN (NEER
C�. A Nqyyqe� DAY. & COMRA V l
CANADA CSG COMI)MY
174801,1ATM, VL 0106
17 480 L 1.7TH W, 0%10 6
t"{s� iLl\fi CA 92790
r0F3'I'w, CA 9718
(714)508-4440 MIX 44,85
USE OF PERMIT
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•
Pi r. WA IJ, B.i.0 1'a'T°
4 ff. WA .LL 43.W G¢r'
Y&FDMTLrD COST CDS' CO1'MU OR
C034ST-RUCTION FEE )01-000-418.000 04, f!
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l;Bt,/ '•.L'.J L+.YT7_. �.i.E'� ,+..I.\.4 \.rr�i.ViiAV d'�J•y,l.�.•iII+1P'lAV CHE' %
$54.00
-LESS PXF�PAD FRE
8 $0.00
S ' x TOTAL PK°'jib r Y0.'S DVX NOW
&54100
RECEIPT
DATE /'
B
DAT FIN ED VINSPECTOR
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
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs S ��
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final _ , 0 3
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Maste 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
COMMENTS:
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)
15/07/01--MON-1`8:127FAX' T
r
W008
0%[S -its'- 02 Ca.
I�
+
WALL
N 86'J5'13' W 111.05'
{{ a LOT pm 1��5
2 +i cI ® G?IJINTA
'BUILDING & SAFETY
ED
.� G FA,gti FOR CONSTRUCTION
No. 31653 2 DATE 3_�a .ZBy
Exp. 12/31/2004
rtgT CIV1V �4 1
E OF CAl1Ff1``c
LAND 1910 S. ARCHIBALD AVE., STE. N
DE"VEL OPM£NT ONTARIO, CA 91761
909 930-1466
®ES/CN fAX f 909 930-1468
S SCALE. f "=20' A
47=205 VIA AN77HES �VCRPORA 170N PLANNING - CIVIL • SURVEYING
LAKE LA OUINTA, LA OU/NTA, CA 92253 OAS' SCALE: s ET: J08 N0. OF WA7FR 0075
03/07/71 11 -20' 1 1 JO65 COT 150
7
go,
=36.42'
2'
+W
-06 JJ 07'
+ y
=18-73'
f`
c
comcRgrr
ORI VFY
WALL
N 86'J5'13' W 111.05'
{{ a LOT pm 1��5
2 +i cI ® G?IJINTA
'BUILDING & SAFETY
ED
.� G FA,gti FOR CONSTRUCTION
No. 31653 2 DATE 3_�a .ZBy
Exp. 12/31/2004
rtgT CIV1V �4 1
E OF CAl1Ff1``c
LAND 1910 S. ARCHIBALD AVE., STE. N
DE"VEL OPM£NT ONTARIO, CA 91761
909 930-1466
®ES/CN fAX f 909 930-1468
S SCALE. f "=20' A
47=205 VIA AN77HES �VCRPORA 170N PLANNING - CIVIL • SURVEYING
LAKE LA OUINTA, LA OU/NTA, CA 92253 OAS' SCALE: s ET: J08 N0. OF WA7FR 0075
03/07/71 11 -20' 1 1 JO65 COT 150
7