0210-246 (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 Ex at
59150°f3 .�'% ��.� 3/C04 -
Date Signature of Contractor
OWNER -BUILDER DEC,I�ARATION
I hereby affirm under penalty of perjury thao'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 ufA'11 F?Policy No. IffSl:si;1.01
(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 become subject to the
workers' compensation laws of California, and agre �tfatd/if I 'I Id become
subject to the workers' compensation provisighs' f'�e for rs00 of the Labor
7. 9
Code, I shall forth th comply with those p�6 1 ion.. /
Date: f ! Applicant `•��� ` "' `" f -._
Warning: Failure to secure Worke%' Compensation coverage is unlawful and
shall subject an employer to crimina(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 applicatdn 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 r pr ,sentat ues this City to enter upon
the above mentioned property for irisecliontpurp es
rf�
Signature (Owner/Agent) r A " #"l"--�"" Date &Ww
�;., -BUILDING PERMIT PERMIT#
DATE VALUATION i stn LOT TRACT
j
JOB SITE� v�. �d
ADDRESS 474x7Q ir' 41fl?60R`C1 NcW
ti�
APN
��
OWN�EeR�
CONTRACTOR / EN611NNEER
�y l n1 �p t� >4. yg �y� �� qp
.'4.r.�`6fFv.ciL.`J'9..T & vlJ.[�X.f'.1'�.N 3`
y/•yD�rESSIIGNN�ER
4d.C'a7.Y��dJ.7'7�A & COtv.LPA KY
17480 X 1711M., #1106
17480F. i'iTH I;'E.4106
1`Lla'179 CA 92780
TLAWIN :A 927850
P14)503-4440 M", 4485
USE OF PERMIT
93 L I.. 61 UA RZ;9N .Al.," 44, L. F. 4'0ARDEN WALL, -11 L.F. 32'
jl P UNNO itl'.AUJ_.ALL ORCO SYS`3 k W
6 Ff, WALL 0121100 I.•li
'LF
1ya,�4y`M4ATM. t,t?W QJF Cfd'MMIRU MMON
3,Q IM..00
CCaAiUTRUC'1IO."i .ITE I0I4101Y•4•18.000 36100
OCT 3 i 2002
' CITYOFLAQUINTA I
FINANCE DEPT,.
yS 'k K
X01 AL CONSTRIK."IT0114 .AND
$63.00
U115 P�AFK-PATDKEMV,
$0100
�N
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
�0 3
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 ,. ,
- POOLS - SPAS
BLOCKWALL
APPROVALS
Steel
Set Backs
Electric Bond
Footings
Z.< <p 2 �97
Main Drain
Bond Beam
�p
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
Gas Test
Appliances
Final
COMMENTS:
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)
08/13/02 THU 10:14 FAX 909 900 1468
I `
L07'1120
,4r
I (2) A/C CONDENSER UNITS ON TOP
OF 3" MIN. CONC
VI N 8 39 52 11 50'
20' 4-� :z £X7RA�tDEPIf7"F0011N '�� rDRIMWA
CRETE 26.
tJ Y65' ,_ g.g� AN 1 O --' R
�
P4
AN
AREA 2, 422.0 S.F.
o et
�I ^ GARAGE AREA = 426.0 S.F. ;� h
Vii• N - � ^
^,�..�• v .1jy,�.,; LOT {ff9 -
o �I e -
$ FF: 60.600
PAD: 60. g
z
o
I BLOCK WALL��
N 8939'52"
If
c C
t o l% fV Ft`
t .
I
SCALE.- 1'-20'
f I
- Q110f ESSI�
Q,'Ex t2/�t/too• LAND 1910 S. •ARCHIBALD AVE., S N
ONTARIO, CA 91761
Civ% DEVELOPMENT 9o9 930-1466
FAX 909� 930-1468
Of .c \f DESIGN
JOB 14 CORPORA TION FLA^1NING -Chit •SURVEYING
47-570 V1A• FLORENCE DATE: SCALE: SHEET: • JOE N0. OF WATER L07S
LAKE LA OUINTA, LA OUIN?A, CA 92253 12/?e/o0 1 `=20' f .Toss cor 119