0103-073 (BLCK),. LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
F- _✓ Chapter 9.(commenci6g with, Section' 7000) of Division 3 of the Business and
Lu Professionals Code;and my License is in full force and effect.
Q M License #. • Lic. Class Exp. Date
�
c Z Date`} _r f! Y Signature of Contractor w e -''"'^
0.
.OWNER -BUILDER DECLARATION
HLU I hereby affirm under penalty of perjury that I am. exempt from the Contractor's
,CL
(n, 4 ; License Law for the following reason:
Z *(.) I,•as owner of the property, o`r'rriy employees With wages as their sole
compensation, will do the work, and the structure is not intended or offered for
Sals (Sec. 7044, Business & Professionals Code).
I, as owner of the property, am exclusively contracting'wiih licensed
contractors to construct the project (Sec.. 7044, Business & Professionals
Code). ,
`-C6 O I am exempt under Section` B&P.C. for this reason
N Date' Signature. of Owner
Orn
a Q . WORKER'S COMPENSATION DECLARATION`
Or Q Cc I hereby affir�er penalty of .perjury one of the following declarations:
, I— 0 () 1 have and will maintain a certificate of consent to self -insure for workers'
X UJ LL compensation, as provided for by Section 3700 of the Labor Code, for the
O:Q performance of the work for which this permit'is issued.
. Q I have and will maintain workers' compensation insurance, as'required by
0. � Q S ce iibn-3700 of the Labor Code, for the performance of the work for which 'this
0-; H' : permit'is issued. My. workers' compensation', insurance carrier & policy no. are:
Z ..
-Carrier . pp, 'AAppn /'y [ �:�y ( Policy No. pip y.�►y {� . y/� .
i"•MS �: ''d9![1'i-F•."siSwi.•.f:u14 E" 4Ain/.i+A`Lf.�i.. IAzfe'afi0'� ,108#r 400
(This section need not be completed if the permit valuation is for $100.00 or less).
J O 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 that if I should become
subject to the workers' compensation provislons+of Section 3700 of the Labor
Code, I shall forthwith comply with those,provlslons ..
3 • Date:"i l r , ;i f Applicant—
Warning:
pplicant Warning: Failure to secure Workers' Compensation coverage is unlawful and
r 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 isherebymade 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
r & hold harmless the City of La Quints, 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.,rep esentatiVes of this City to enter upon
the above-mentioned propertyfor`inspecttion purposes. ;
Signature (Owner/Agent) Date ry 1
Y
BUILDING PERMIT PERM T#
1(,Y.
DATE VALUATION LOT .y'tj TRACT rr
"'16 1, 52,
JOB SITE
!
ADDRESS
4•- 9011 VIAL —_ia, /VD�c,J� 0
IAPN
,
t
OWNER
CONTRACTOR/ DESIGNER/ EN (NEER
17480 P_ 17THT S', M. 06
•17480 X 17M Ur. #106
xzf:: r.'A 92180
T(Tt"MN C 92790. '
USE OF PERMIT
ORCO STAH6ARD.
Ft WA1.1 45,90 LF
as FT;'WA.LL X8.00 'LF
CIONV't'dL'.4"a7:10W R2 101.01W418-000 'f,t►9
"AfG4 ' /- MIN -4 CITE=
'$54.00 `
X EW S'RU-P n
$0.00
ti}'1� "FLRS T Nom
9�a 1Q1Qf
REQEIPT
DATE
BY ; '
DATE FINALED
INSPECTOR
r
4.
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
Footings ` y_6� ��
Bond Beam �/�
/
Electric Bond
Main Drain
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
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:
-
• ' . 70.
LOT X71
J
J
Q
N agw,5?' £ fas 50' 3
z
o BLOCK WALL
SpA 7117' .
i X
I. to' u711/TY
w . I £ASfMEJVT , o
LOT j70 .
P=
i PLAN 10 w
L/VINE AREA =.2,422.0 S F.
S g I
2 GARAGE .S.F. S z
2
a FF: 63.20 z1a
PAD: OR r
62.70'
6s
00
W. E 100.50*
BLOCK WPIL1.
LOT p9
F -I
SCALE.• 12620'
SOP 1910 S MCMAW AVE.. SW_ N
�ND ONTARIO, CA 91761
D VFLOPM£NT' 909 930=1466
$IGiV FAX (909; 930-1468
,�/(01B ADORES °`
. ORPOV?A 110N pLAw"c avlL • suavElrtNc -.
47-900 VIA IR/ESTE SHEET-, ..,IN No. of wAW? ',LOTS