0203-095 (BLCK)LICENSED CONTRACTOR DECLARATION
I hereby attirfi'i unaer penalty of perjufy that I dill limised widui piuvlsluiis Uf
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# Lio.Class ,v ExIf.pates �
At //591,561 H
m/402 -Signature of Contractor
I
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).,, r
() 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.
1 -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 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 should become
subject•tothe workers' compensation p�vi ion ofe o�3700 of the Labor
C.gde I ,h}l :f it comply with
Date: ^.•'/f 2 Applicant
Warning: Failure to secure Worker Compensation coverage is unlawful and
shall subject an employer to crimi al 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
fora 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,epres Ktative's�of this%City-to. enter• upon
the/above-mentioned property fo✓r�int peeti n purpp es.
Signature (Owner/Agent) ��•'✓r�✓' ���t� Date /
,.
BUILDING PERMIT PERMIT#
DATE /` VALUATION LOT TRACT
✓ J ?../ <3 6� !�.a. i#:: °�.Ct3Z
26152
JOB SITE APN
ADDRESS 42-163 YM l NTMI� y ^
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OWNER CONTRACTOR / DESIGNER / EN 1NEER
OP14ADAY & C0WdsRY CANADAY A: a �`OMPI.M.•_A. 92780 IUS CA 92780
. ,
1748OX VnIlUT 0106 17480E 1711M.016, 01'
('714) 084440 ;.::' • CB. 1 ~ 4485
USE OF PERMIT "F
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6' &44 'L.P4' t D1W. WALL, ORCO SYSTEM
6 FT. WALL
4 FV. WALL
85.00 U?
44.00 L
Rr OF CTaMMT7'MON
[01-000-416-000
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JIFISI PRE—PIOM
$54.00
MDO
MAL PERA'1:1 5 DX* NOW
i ^'RECEIPT DATE / BYDATE FINALED INSPECT
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
3. l
Equipment Location
Underground Electric
Underground Plbg. Test
Final I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plurr"ing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sews 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:
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No. 31653
Fap. 12/31/2004
WOW.
N 83b8'30P
W 110.67'
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LOT ,x/48
N PLAN 2OR-8
L/WNG AREA = 2,595.0 5.F.
GARAGE AREA = 426.0 S F.
FF: 61.80
PAD: 61.30
66FOO 77
0 4' EXTRA OEp�
OCK WALL
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.47-165 19A AN179E5
LAKE LA OUIN TA, L A OUIMU, CA 9225.3
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( CITY OF LA QUINTA
{ BUILDING & SAFETY DEPT.
APPROVED
FOR CONSTRUCTION
DATE 3�/�,-p Zsy
ND 1910 S. ARCHIBALD AVE.. STE. N
fifWLOPMENT ONTARIO, CA 91761
909 930-1466
®/ESS/GN FAX 9093 930-1468
�VORPORATION PUNNING • CIVIL - SURVEIING
DA E:SCA SHEET: JOB NO.703F WA1FR LOTS
05107101111-20' , J"W5 Lor 748