0210-247 (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 Business: and'
Professionals Code, and my License is in full force and effect.
License # Lic. Class E . Date
/3 1104
Datei9�Si nature of Contractor
OWNER -BUILDER
I hereby affirm under penalty of perjury that'l 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).
( ) 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 w�'1' fr I+?)1"I ' Policy No. 16,61391-01
(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 becorpe subject to the
workers' compensation laws of California, and a ree;6i�F &t •f/I should become
subject to the workers' compensatloo 10 f 15,n 3700 of the Labor
�.
Code, I,jigiyifgrt1AViJV,,9omply with th6Js p ,Sio�n's„
Warning: Failure to secure Worker KCompensation 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 applicai 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, andJSt te�%OsOeIatiRg to the building
construction, and hereby authorize re - t t'ves oT this City to enter.•u on
the above-mentioned property for'Ins�ctt4n U os S.
Signature (Owner/Agent) ` ��" '" Da -4f ,
BUILDING PERMIT
PERMIT"
.Fy.
dJ123 2�1'?
DATE VALUATION LOT
TRACT
JOB SITE
ADDRESSpi,�leCII�Q
APN
OWNER
CONTRACTOR / DESIGNER / ENGINEER.
CAZ,dADAY.Fx COMPANY
''t�4. T DAY A COMP'ANY
17480:EG '1.7'1 Orf, '4106
1741801 E, 17'.P°lri01.', #1i1
(714)508-4440 cW10
4485
USE OF PERMIT
GE11 IM L IM1111s,N
$0 4F. 6' C,tA.A —NER WALL, 60, .L Y..4' QAD4 WAJA, 7%' t,F. 33'
6 FT. WALL
_Moo 31F
Q rr. IWALF,
60.Ot1 TIF
ENT 411M colvr OF COMMUZ11110 11.QK
31210M
C ONS RU , l; l'?r1.FE y ; 101 w1,q y.41 000 " X6;1,€D
:
OCT- '3
.i ?ti07
CITY OF
F FINANCE
LA QOINT A '
DEPT.
LEW,. ITMPAU) FEES
$0 00
'1~MAL PFRIMT
FRES Dom; AOW
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
.a
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
-`d
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Footings
Electric Bond
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final Z.
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
Gaq 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:
U8%13/Uz 1•HU 1U: 14 FAX 909 930 1488 1Qjuuz
LOT 1121 {
r
+ _
V I N 89 :i9 52 111.50 i
w LOT #120
r
PLAN 10B "
' LI WNG AREA • = 2,595. 0 . . F.
o GARAGE�AREA 426.0 F o;
r
g FF: ' 6.0.80.
CO CR60.30
z PAD: �
.
DR Y 2
A 65' 26.5'
�. BLOCK WALL
N 9J952: £ 11"50' ' -
- —
(2)'-A/C'CONDENSER UNITS ON TOP
°. OF 3" (MIN.) CON PAD
• LOT ,/119 ..
SCALE.' 1 "=20' • ..
•
y' . '
P�OFESS� F a 4
o
'
1910 S.. ARCHIBALD AVE., STE. N'
z LAND • ONTARIO. CA 91761
No. 31653
Exp. 12/31/2004 DEVELOPMENT(909) 930-1466.
DESIGN FAX (909) 93071468
OF CAUF� CORPORA -TION '• PLANNING'• CI VII •SURVEYING
47-540 VA FLORENCE DATE: ' SCALE: SHEET: JO® N0. OF WATER LOTs
LAKE LA OWN TA LA QUINTII, CA 9225) 02121/02 17 =20' 1 3065 LOT 120