0203-371 (SFD)79805 Ambassador Cir
0203-371
LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Ht1. Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
d W Professionals Code, and my License is in full force and effect.
O =) M License # Lic. Class Exp. Date
oZ r- Date / r - Signature of Contractor ' ' ` t ;f ;'t'f. _ '`
CD Q 11-
J U coo OWNER -BUILDER DECLARATION
LULu I hereby affirm under penalty of perjury that I am exempt from the Contractor's
to License Law for the following reason:
Z_ ( ) 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).
M () I am exempt under Section B&P.C. for this reason
LO
N Date Signature of Owner
ON
0)
Q WORKER'S COMPENSATION DECLARATION
C, 2 Z I hereby affirm under penalty of perjury one of the following declarations:
Lo O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W Y= compensation, as provided for by Section 3700 of the Labor Code, for the
Q J Q performance of the work for which this permit is issued.
CD Q U ( ) I have and will maintain workers' compensation insurance, as required by
Q U Q Section 3700 of the Labor Code, for the performance of the work for which this
Il 0 Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier 001,012M KAOIX 1148, Policy No.
00 =)IOVC-54068.03
0
J
(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 that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
j Code, I shall forthwith comply with those provisions. y
Date: o,- Applicant
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, and State laws relating to the building
construction, and hereby authorize representatives of this City to, nter upon
the above-mentioned property for inspection purposes.
•- ?R _f ri t .
Signature (Owner/Agent) d ' '` Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOTS -j TRACT
t
7''
M j • ` ' c $ 03070,60 tri 24197-5
JOB SITE
APN
ADDRESS 79_W.5 AMBASSADOR DOR CsMGME
604-0724M
OWNER
CONTRACTOR/DESIGNER/EN (NEER
1'1535 6701 So OT'42Wrl =10200
151.45 130, I'D' >STI&II 1, ITI'> I 0200
SAA MNARDNO CA 92408
3RN' T3'ERWARDWO CA, 92408
t90 l i l> t 00`7 ORT 2120
USE OF PERMIT
SPJJ - WT 13 PLAX 3A., PERMIT DOES NOT INC.I.d IM), HI)OCK WAi..'.
P004 SIPA. OR D:RIVEW:P,.''a' APPROACH, 73% PLAN CHECK Fyf RIrDi C11,'10N
IK)R MULTIPLY I=U ANCE, OF SA,MB PLAN TYPE
TRACT t' ONSTRI.WTI N 1,7MOCI SF
Pc7ROYPAT IO WAD sp
GAR- AWCARPORT 41#.00 fSF
FESMATKD COST OF C009KRUCITOH
10.3,0-m.60
CONSTRUCTION FEE 101.000.411 -000 503110
PL." CHFr_K FEE 101-0001.429-•329 $136.02
MECHANICAL f'Tt.1 101-000-421-000 $60.0a
EL..B0TI::IC.AL. B7_ 2(21 -(=-MAI -000 $11774
PLUMBING FF'? 101 -000-419.0010 SI M00
STRONIU1IION FE& - RESID 101-000-241-000 V rl1
(31R rMC0 FEP, 101-000-423-000 $20,00
DEVI SLOPER IJMPAX-T F?1E $I,9?.00
-m,
atrg- c a rOWTRUC 1101 ' M -) PITS CRECUC
$3,034.W
e
FEWMT
MAY U 1 2002 '
`
IIIIIIIIIIIDIII IIIIIIIII 12
CITYOF AQUIRTA
IE
FINANCEDEPT.
RECEIPT DATE
B1: /
DA/TE INA D
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
_
Underground Ducts
Forms & Footings
Ducts
Slab Grade
r-
Return Air
Steel
o
Combustion Air
Roof Deck
-3/ -
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
-
Compressor
Insulation :
/ -per
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
_ T - d
Final B L 5
BLOCKWALL APfyROVALS
Final
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
::5-7_ =Z s
Heater Final
Water Piping
1522 GC2
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
_ ? . J Z
Encapsulation
Gas Piping
Gas Test
Q • /S'„o 2/ +
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring 272—
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) ! Q Z
COMMENTS:
Certificate of Occupancy
; . City of La. Quinta
Building and Safety Department
This Certificate issued pursuant to the requirements of Section 109 of the Uniform Building Code,
certifying that, at the time of issuance, this structure was in compliance with the various ordinances
of the City regulating building construction or use. For the following:
BUILDING ADDRESS:
Use Classification: SINGLE FAMILY DWELLING
Occupancy Group: R-3 Type of Construction
79-805 AMBASSADOR CIRCLE
Owner of Building: CENTURY CROWELL COMM
Building Official
vni
Bldg. Permit No.: 0203-371
Land Use Zone: RL
Address: 1535 SO. "D" STREET #200
City: SAN BERNARDINO, CA 92408
By: STEVE TRAXEL
Date: 12-09-2002
POST IN A CONSPICUOUS PLACE