0011-056 (BLCK)` LICENSED CONTRACTOR DECLARATION
| hereby affirm under penalty of perjury that under provisions o,
.
6C*Apte,9 (commencing with Section 7000) of Division umthe Business and
Professionals Code, and myiuinfull force and effect.
'
License # � uu.o/uos _ Exp. Date
.."Date ,
/ OVVNER�9U1LD�R0E���RADON
| hereby affirm under penalty ofperjury that |omexempt from the Contractor's
License Law for the following reason:
( ) |, as owner of the pmporty, or loyeeo with wages as their sole
compensation, will dothe work, and the structure |onot Intended nvoffered for
sale naoo & Professionals
( ) |, as owner of the property, am mm|uu|ve|y contracting with Uoano.e6
onmmnmm to construct the project �on. 7o4�. Bu�?000 Professionalsn�
Code).
' '
< ) ! am exempt under SaoUnn _�. o&PC.fox this reason
Date Signature -ofOwnor'
WORKER'S COMPENSATION DECLARATION'
| hereby. affirm under penalty of perjury one of the following declarations:
( have will maintain acertificate ofconsent mself-insure for workers'
oviiiponisauion, as providod.fot by' Section 3700 of the Labor Coma, for the
performance ofthe work for which this po,minoissued.
(./)` xmeand *iU main�inwmmm�'onmpenv�ion insurance, aomquimdbv
Section 3700 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. '
J0mslukcm A1Jnw. 0�
(This section need not bacompleted if the permit valuation is for $1OO.00o,|oxo.
() | certify that inthe performance ofthe work for which this permit ioissued,
| shall not employ any person in any manner 000sm uocnmo subject mthe
workers' compensation laws mCalifornia, and agreethat if| shouldb
Subject to the workers' compensation,p isions' of *9tibn 3700 of the Labor
Applicant— 40 '1
,,,Warning: Failure to s6cure-Workels' Compensation coverage is unlawful and
addition to the cost of compensation, damages as provided for in Section 3706
cxmo'Lauo,Code, interest and attorney's fees.
IMPORTANT Application |uhereby made uothe Director moui|uinganuSafety
,
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 i ed undero,pursuant on
any permit issued 000 result cxthis oppncotonagrees to, m ahaU, indemnify
a hold
'unn|eoo the City of La �uinoa, its officers, agents and employees.
2. Any po"nn ioouau as a result oxthis application becomes nun and void if
work is not commenced within 1$0 days. from date, of issuance of such
pennit, or cessation nfwork for 100 days Will subject permit to cancellation.
I certify that I have read this application and st6lte thatthe above information is~
correct. I agree to comply with all Cityj 'and Siatdl'atWk relating to the building
construction, and hereby authorize represehtatives,/�f this.,Cit"Y-6 enter upon
the above-mentioned propertyfpl� inspectic(r*�,purposies--'
Signature (Owner/Agent Date
DATE qALUATION LOT 0011-0!56 TRACT
JOB SITE APN
ADDRESS
OWNER CONTRACTOR DESIGNER ENhINE;:R
TUSTIN CIA 92780 TUMN CIA 92780
(7/14)508-4440 CBIA�, 44,S5
US E OF PERMIT
STANDARD
4 1?1'. WALL silo LIP
FRE 101-000-416-000 SKIDID
TOTAL DUE Brow Z4,00
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
FootingsNv
Bond Beam ,4rZ�
(IZ)
�G
Electric Bond
Main Drain
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Gas Piping
FinalS%
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:
..
,f
J
J
LOT #124 \
N ,1 � Zo
� na
I BLS. WALL I j W '
0 4 EDF 66. 21.881 ir r
2 .64' I W oz
I E� PIAN 20 R L��S F 10 Z
R-318.50
- i s40 I i�WAY OFF A� _ 2,595:0 S.F
p o5 �.�' LiONG A AREA 426 ZI �.
,.
GARAGE• N I04
0
10' 60 80 Q I 3
.:?t I J s
lv Q J o
W• N I ��' ,. , 3, o I Z
42, Z
a 3 I LOT #1� �I X
EDF
Q I ` BLOCK `WALL
Lo
2 N 89 39'52 " E 111.50'
LOT #122 ^°
✓OB ADDRESS
' 47- 440 ' kA • FL ORENCE
' 4 LAKE -LA QUINTA, LA ,QUINTA, CA 92253
LAND 191-J S. ARCHIBALD AVE.. STE. ,N
ONTARIO, CA 91761
DEVELOPMENT (909).930-1 " 466
DESIGN FAX (909) 930-168
CORPORATION -PLANNING CIVIL I.SURVEYING
SCALE: l`-20' DATE: ' SCALE: SHEET: ]JOB N0. .
04/04/00 1 320' " 1 3065 LOT 123