0210-250 (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 Businessland
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Datq,
1591561 B
U&x efff�
Date rSignature of Contractor
OWNER -BUILDER DEC_ 4RATION
1 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 (EW, 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 issued. My workers' compensation insurance carrier & policy no. are:.
Carrier �T• IE.1�'lMD Policy No. 1661391 .0It
(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 tha3 if/should become
subject to the workers' compensation pr•, Isl S1 �o i6 3700 of the bor—'
t, " P
Code, I hall forthwith.comply with th • se pr vI +o s
Date: ZI/`pplicant
w �-
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 applicator 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 repres ntpiv of this City to.enter upon
the above-mentioned property for. i pp6t' n • ur, 4s. y
Signature (Owner/Agent)/�Date
BUDDING PERMIT PERMIT#
. __ r.:. DATE VALUATION�f. LOT TRACT
tSABiy. .�i� r.F�9.9 i 26
JOB SITE
ADDRESS �'%•-+s'� a��A �iS.L�F r
APN
OWNER "
CONTRACTOR / DESIGNER / EN (NEER
CARADA`f & CC>MPAN't
t:AAr's°MAT & COW. ANY
1703,0 F 17711 VY, #106
17480 R 17TH M,AA06
"t�tr Tlr CA. 92790
TUVR4 CA 92,160
a4)5013 -4j140 �: "� ,p3
USE OF PERMIT
GlkMMI AAL F3U.SLi:)ING
130 L IK 6' t~t!h:l.'.DZN 'IV.AU,, 46� %,.F 4' tt1t,1 DFW WdA- , f1t;2TF% 0111 -CO
6 FT, W&A, 190,00 1110
4 In'. WALL, 46.01) 1.,F
COST OF�;"�1N�,"�fL���'®3.IG
5,230_00 .
p�qQq;��ryy'��qq���• •� f�','y�7 �1 h ��5�',1.1:(1d,A.1"
CONSTRUCTION FEE 107.-000.08-000 $81.09
OCT ,3 1001
CITY OF LA
QUINTA
a FINANCE DEPT,.
TA r0TAL C11014r6rii(:Illow AIM 1>11
PM
.00
RECEIPT
DATE
BY
DATE FINAL D
INSPECTOR
-7 -03��
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 , p S%
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
_
Final p
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:
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LOT J126
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SCALE 1'=20;.
oL l/ING AREA = .2,422. 0 . S. F.
'426. 0 S. F.
,
o� LOT
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RAGE AREA . _
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..�y
FF: .60.70.'-'..
'
PAD: 60.20`
tom: 31653
W4
-OFCIUF
" CONCRETE
JOB ADDRESS
ORYWA Y
47-350:,1/!A,
FLORENCE
_ — -' N '� —• -- `
LAKE LA
OU/NTA,, LA OLVINTA,' CA 92253
LAND
1910 S. ARCHIBALD AVE., STE. N
` R=31 0
DEVELOPMENT
ONTARIO, CA 91761
9os 930-1486
�909�
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L=65.29' v ��
,
DEIGN
t AX 930-1468
6=11444.) R
T -J2.76' o
* ~
C6RPORA77ON
PLANK .., • CIVIL - SURVErNG
IIIA F
L ORE'Nr`
`
DATE`,
SCALE:
11-20'
SHEET:
JOB N0
OF WA T1 R+COTS
1 126
'
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—
1/29/01.
1. , )065 LOT