0307-198 (MFD) LICENSED CONTRACTOR DECLARATION
BUILDING PERMIT PERMIT#
Cr;> I hereby affirm under penalty of perjury that I Dam licensed under provisions of 0301-198
H Chapter 9 (commencing with Section 7000)of Division 3 of the Business and DATE VALUATION 026,3163'* LOT U5 TRACT 2030
cel W Professionals Code,and my License is in full force and effect.
`— License# Lic-Class Exp.Date(3 r� � r '1 1/73 JOB SITE. IT&O-45 kVENUE,4tI
) O T+ APN MI,M-041
LLJ ADDRESS P
Z r— Date ��`_�< +T Signature of Contractor- `� � � � OWNER CONTRACTOR/DESIGNER/EN (NEER
J U CID OWNER-BUILDER DECLARATION 5'I6 O�(;i?,,�,CH1: T.i�1+ �J' 'R I40 11 ;1JQ3KtK1AY`F}`i &i 1,14 QtT,!] rui C.!.�'r.9i 153
U W r- I hereby affirm under penalty of perjury that I am exempt from the Contractor'sC T.+:1 C t� (��, ;s'j �3 k JQIy Z� r( C`i C"l-k 92138--0:i
~ a g reason: 4,License Law for the following , r
fA � �'�:�'D'•4•:.7�5
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). USE OF PERMIT
( ) I, as owner of the property, am exclusively contracting with licensed 1%fW T1_F?MNMY'I MEUUNG
contractors to construct the project (Sec. 7044, Business & Professionals
Code). �.. .. ..•...,.., .. ,u
cY) () I am exempt under Section , B&P.C.for this reason SPRIi2dKIAMED,1.19 UIT DOES WC4�,XCI,U:!F OW,K tip,i"'00L,
LO
N Date Signature of Owner
ON
a Q WORKER'S COMPENSATION DECLARATION'
o CC I hereby affirm under penalty of perjury one of the following declarations: uP1Q:11'KLER J:'4 'o xv,
U-) H O ( ) 1 have and will maintain a certificate of consent to self-insure for workers' UC••C0MMZRCW., 9,ma-.6o ZF'
X U compensation, as provided for by Section 3700 of the Labor Code, for the COMPACT AMOUNT 2K,1141M 1'41
mJ Q performance of the work for which this permit is issued.
Q < ( ) I have and will maintain workers'compensation insurance,as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
d rn H permit is issued. My workers' compensation insurance carrier & polic no. are:
� Z Carrier =X11&'reflo"11 Policy No. `�'l�w3r�7� iP-14L L ypd yy����}y g yn,`hyNA'�`:E'nMIX—"/C'-Off OF t. a?�s�'�i �ii�,�rC3f� 326, 16.00
CONN
Q (This section need not be completed if the permit valuation is for$100.00 or less).
RUCTION FEE 103.000.41
J ( ) I certify that in the performance of the work for which this permit is issued, PLAN CHECK FEPI F��-JOa7"dad-3FI4 aF,�U1•d5
1 shall not employ any person in any manner so as to become subject to the MECILANICALM 101-000.421-00Vi
workers' compensation laws of California, and agree that if I should become ZY..lXTRICA,,L !EE 1f3F•G��-��ti-�'.> ��3'a.$i
subject to the workers' compensation provisions of Section 3700 of the Labor I�tlPlf s'INO FD7 t 41•�7Gt?„4 I S�OdI> 81341. it
Code, I shall forthwith comply with those provisions. 3 �,,; •,
Date: r ' 1, .,- . Applicant--` - S 1 F;O�O MOT.C.14 FFE•RZE.AD 1..01 13OU-�A•2-f55{°; ��.6'f
. ��-,. �. w,_._ GRNC
C# IW301-0004”3 i)t5��,.
Warning: Failure to secure Workers'Compensation coverage is unlawful and F3I?VEI�T�E.�2 FMPR.C`S FZZ �17slZlfl.nG
shall subject an employer to criminal penalties and civil fines up to$100,000,in AV W PUBLIC PLACES-RE-Sift:VO-OW-445-000
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 MT—TOTAIr CI N'SMITC71,40H ANT)!.=i_AV 'a.'.•'Y K 'l 6,2A 1.112-
whose request and for whose benefit work is performed under or pursuant to 1v,? 1 Ysw1Y '�; F'7G�, a
any permit issued as a result of this applicaton agrees to, &shall, indemnity D
�. & hold harmless the City of La Quinta, its officers, agents and employees. TAY,Y'E181M*FLFF!-,,)D,�a"�;�N,710N t~ 1.9.2
2.Any permit issued as a result of this application becomes null and void if AUGwork is not commenced within 180 days from date of issuance of such A0.1 1003
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 CITY 0-LA OUINTA `I111111IIIIIIIIIIIrJ111I 73
' correct. I agree to comply with all City, and State laws relating to the building FI.INAIcCE DE,,PT
construction, and hereby authorize representatives of this City to enter upon �� IE
the above-mentioned property for inspection purposes. -
¢ RECEIPT DATE BY DATE FINALED I INSPEC
Signature (Owner/Agerit) - Y Date t�• , �' 'd +f-� 3 0 -
INSPECTION RECORD
i
OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR
BUILDING APPROVALS MECHANICAL APPROVALS
Set Backs Underground Ducts
Forms&Footings3— Ducts
Slab Grade 3_y Return Air
Steel Combustion Air
Roof Deck . < Exhaust Fans
O.K.to Wrap 3— p- F.A.U.
Framing y- Z/—y 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 f 3 e,'
Final POOLS'- SPAS
BLOCKWALL APPROVALS 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 Final
Plumbing Top Out Equipment Enclosure
Shower Pans O.K for Finish Plaster
Sewer Lateral �,• .. <j 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
Fb(tures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp.Use of Power
Final
Utility Notice(Perm) / _
m.
Certificate of Occupancy
IHCORFDNA7ID 4.
OFBuilding & Safe
ty Department
This Certificate is issued pursuant to the requirements of Section 109 of the California Building
Code, certifying that, at the time of issuance, this structure was in compliance with the
provisions of the Building Code and the various ordinances of the City regulating building
construction and/or use.
BUILDING ADDRESS: 78-875 AVENUE 47 BLDG,B
i .
s Use classification: MFD '
f � , � Building Permit No.: 0307-198
Occupancy Group: R-1 OCCfGroupl Type of Construction: V-N
YP Land Use Zone: MDR
-Owner of Building: SCPH Address: 516 BURCHETT STREET -
City, ST, ZIP: GLENDALE CA 91203
By: G. SHOWALTER
I I Date: 12/23/04
Building Official
i
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