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0203-378 (SFD)79762 America Ct 0203-378 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 Exp. Date 714 188 "a 1011„ i /fill DateSignature of Contractor OWNER -BUILDER DECLARATION I hereby affirm under penalty of perjury that I 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. (,N)- 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 04°1I.I1 A1pA(;I g INS. Policy No. vC444068-03 (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 Code, I shall forthwith comply with those provisions:') F Date: i•. Applicant T > ' • u h.. w.. , 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. t 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 enter upon the above-mentioned property for inspection purposes. Signature (Owner/Agent) Date 2" BUILDING PERMIT PERMIT# d DATE VALUATION S1 797qq 03 tt'' q0 60,ry, LOT pp 0M.178 TRACT 74197-5 JOB SITE ADDRESS 79-762 A1I✓WR1:L°A WOW APN OWNER CONTRACTOR / DESIGNER / ENGINEER d ±N'C►3 (°,Li0j.,L CahSM. 1 V jor C1♦ 1' CYy C 011100 155 • 35 301 o 'MR M11 11 R 011100 igti?'!l rL Cry!C 3 &a5ilf yi3 ll JJ hlt i. lA} 6i 1' t 1 Jy a71iM S•L 4 RAN .E•zEWAM)NO CA 92409 SAN x. E1A2DWO CA 1".408 (9))381-6007 C1?W 2120 USE OF PERMIT OLE RA&Ml I DWEXI1+7 A SM ^ Lt` T 22 PLAN T€RIM. PERMIT 210M NUT INCLUDE II•p.t.0 WAI,I.,S, ;0flt, .L, if1,A. OR DRVV'E;1AiAY A.k' PR.O.ACFl, IMA PLAN CR CI;..FEE REDUCTION FOP, MUI.'{VLE ISSUANCE OF .SAMA', PLAN TYPE TRACT CONSTRUCTION 111725.00 SP PORC` IPATi'.IO 01.00 Sk' tM.AGEUCAI PORT 419A W ESTWATM) COW OF CONSMWCMAK M10110.60 Pia n HIIE IMIKARY CONO RUCT-10i4 TEE 101-000-418-000 W3150 T LJi .11 CHWK FM $146.02 A+ ECYIMIQ; L ITZ 101-000-A21-000 160100 9,LW,TMC•AL ',FEZ 101.000420-000 Ill i 17.24 1~'Gi1MB11140 Pet 101-00,0-419-000 f 3 1, OfI S'TRONO ISOTICJN FSE - RI ESLD 101-000-241-000 1e.st GIP d DDI0 3r')r$,: 107.000.423.000 fi f1 +3117 xblrTZLOPER IMPACT PF -1? a.9 N l i1D•-T_MWL i`0NMUC1:10N AND PLAN C,.E X $3,034.07 DU LESS IM-WaD DE"90 ZOO \ 1114 :! RLJItiL'4 1r A.' S 1 j3 D 6+ C. 1`1O'LY eA I ln 410 4 MAY U 1 2002 0WORAQUI 4 E`IIIIIIIIIIIIIIIIIIIIIIIII 50 }, FINANCEIDEPT. l IE J RECEIPT DATE BY DATE FINALED INSPECTOR me INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Underground Ducts Forms 8 Footings _- p - Ducts Slab Grade 6— — Z Return Air Steel Combustion Air Roof Deck �� _ Exhaust Fans O. K. to Wrap F.A.U. Framing —© Compressor Insulation .p Vents Fireplace P.L. Grills Fireplace T.O. Fans 8 Controls Party Wall Insulation Condensate Lines Party Wall Firewall Exterior Lath • Drywall -Int. Lath Final Final (� —z- BLOCKWALL APPROVALS POOLS - SPAS Steel Set Backs Electric Bond Footings Main Drain Bond Beam 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 Top Out Plumbing Final Equipment Enclosure Shower Pans O.K. for Finish Plaster Sewer Lateral Pool Cover Sewer Connection Encapsulation Gas Piping Gas Test dt J .o s— .17 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 /� Z Utility Notice (Perm) -pY 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 79-762 AMERICA COURT Bldg. Permit No.: 0203-378 Occupancy Group: R-3 Type of Construction: VN Land Use Zone: RL Owner of Building: CENTURY CROWELL COMM. Address: 1535 S. "D" STREET #200 lJb 't Building Official City: SAN BERNARDINO, CA 92408 By: STEVE TRAXEL Date: 12-16-2002 POST IN A CONSPICUOUS PLACE