0012-298 (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
Date Signature of Contractor'
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 6Wfier of the property, am 6i dlUi W6lji contractlhg With licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
( ) lam 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.
cs) I have and will maintain workers' compensation insurance, as required by
Sec ion3700 of the Labor Code, for the performance of the work for which this
i
permit s issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
24MM41ftOfiRM00 ..
(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 -t) at if I should become
subject to the workers' compensation provisions•gf'btion 3700 of the Labor
Code, I shy rl�f �rtiJwith comply withthose provision
Date: 9 Applicant I
i
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application, is made & each person at
whose request and for whose benefit work is performed under or pursuant to.
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
.permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is .
correct. I agree to comply with all City, acid State laws relating -to the building
construction, and hereby'authorize-representatives of this City to'eriter upon
the above-mentioned property for inspection purposes.
a
Signature (Owner/Agent) �f=^^ � Dates '-_/' '1 rfi ,
r T. F
` BUILDING PERMIT PERMIT#
DATE ({p VALUATION LOT TRACT
) 't Q3d�lf ', 2A of 615 2
JOB SITE ' APN
ADDRESS
OWNER CONTRACTOR/DESIGNER/ENGINEER
'o✓Af.°IAL?A:R 14X11010)4 pa i. CARADAY & W\J.F.V.3R'1l'NY
2780
TUMM CA 92780 3,00 CA 9
USE OF PERMIT
.k'3�s,.iktlti.7,�a7.A'P5.7' r
2.5 LY. OM; 1ANE ` O B1* `5'O UL LIST&,f;: APPLIANCE, ONI.X
VALUNTION
F
Rgqm:Z�4y��gg4':'�T`//� r��79�.T�'.M.�4.�$Y ply {{�/y
P.GTi PPIAM1 i'YrE 101 _000'4 i51,11-000
S,l r�r.NQ
AT, CON 'Xrft UCTKYRAND 'PLAN MIMIC $18.00
X6 PREIPAT13 F E19 AL3, t3U
RECEIPT DATE + �� ,� r eBY. •�l I D�l[IA[LF_D/^ INSPECTOR
Lf NI f ZW o
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
Equipment Location
Underground Electric
Underground Plbg. Test
Final
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 9 ��
Gas Test
Appliances
Final
JL -
Final I
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Extarior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
t.
�72� .� r
y, k
' LOr V12s
ALL 4 EDF w ,h
\REQ
2,422.0
cM CONCAY FF AREA X26
E /
\p RIVE\ �J�0 G AREA 6� 60 � 3a_s2' g
m. 'GAR F� 6� �p : a
'\ �
G f #12`� r `
R=318.50' ,
L=60.95' E \ EDF `116.23
T=30. 57' 2 p8
;
=10 57'52- 10` 1 N X6'18'
\BLS
UTILITY WALL
1/ EASEMEN
ell
CITC OF LA QUINTA • coe�ui� -fry.: '
BUILDING &•SAFETY DEPT.. L.rs-� .
APPROVED
FOR CONSTRUCTIONOil_DD SS
N—
ATE 12 + �47x4f0-1/lA�1A"FCORENCE=��
t, BY
LAKE L-;4 `OUIN.TA,- 2-A OUINTA, CA^92253
` •' . LAND 1910 S. ARCHIBALD AVE., STE'.` N
ONTARIO, CA 91761
DEVEL OPMENT909) 930-1466
DES/GN FAX 909) 930-1468
SCALE.' l'--20' 'CORPORA TION PLANNING • CIVIL • SURVEYING
DATE: SCALE: SHEET: JOB N0.
' 0410410Q 1 =20' 1 3065 LOT 124
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BUILDIN & T.
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