0307-200 (MFD) LICENSED CONTRACTOR'DECLARATION PERMIT#
I hereby affirm under penalty of perjury that I am licensed under provisions of BUILDING PERMIT �7"
H Chapter 9 (commencing with Section 7000)of Division 3 of the Business andI+r�
DATE VALUATION CN?'W"40,c�m.•AS+.'9L� LOT '•�.� TRACT 24.2.3 k,)
04 W Professionals Code,and my License is in full force and effect.
O =) M License# Lic.Class Exp.Date
r- 0 Ln 194 31, B C-S:-'ur- M 1/02% JOB SITE 7a-975 ANMP3-UX,.a X17,11LD ,.�' APN ,r=l:�-*51U_014
r ADDRESS µft c
Z ,Date OWNER CONTRACTOR/DESIGNER/EN INEER
A Signature of Contractor
C:) ,�. r.;;z:z. csr�„wc. ;U �iUpa r.:o.,: r�:.
o. ,
J U cp OWNER-BUILDER DECLARATION 53611,I)RG`lll', �►"'1TtM 78-�i01 r11�11�.4�t.1 111 #'.+:LAQ!W.1'lfa:;A�+�:.53
H LU I hereby affirm under penalty of perjury that I am exempt from the Contractor's 01,M)KH, CA Q 12W SXM)�+M(~,•0 CU.'-, 92139,0'1
N License Law for the following reason: �6,: -MY7.4.156 (71114 16JF7
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 IwSflI.3 f- �l ;'i'rJ'U .Tf�*�
contractors to construct the project (Sec. 7044, Business & Professionals
an•. ,..a c«» ar.•n ,acee� ,,.rwrr«.,.r,a •rf c r.�R. ..•trs'mcr+:s
Code). �s .. .. .. .a. . . .„..., . , . ,
CY) () I am exempt under Section , B&P.C.for this reason SPRI1dPMER t' Pk;'WITi DO MW NOT I1d K'I,,UDE.IBLOCE: iVALUS OR POOL
N Date Signature of Owner
OC\I
ZWORKER'S COMPENSATION DECLARATION
o Z I hereby affirm under penalty of perjury one of the following declarations: I'Ii11i a1. R ! ?.�°tft c1
U') F- Cc
O O 1 have and will maintain a certificate of consent to self-insure for workers' .A41C,•C I`}BI1Min;CU.1r 6,us.w uii'
X W �= compensation, as provided for by Section 3700 of the Labor Code, for the CONT;tWI'E',f0W)UNT A519_46.30 LS
O � Q performance of the work for which this permit is issued.
m Q I have and will maintain workers'compensation insurance, as required by
OU Q Section 3700 of the Labor Code, for the performance of the work for which this
rn H permit is issued. My workers' compensation insurance carrier..& polic no. are:
,ItZ Carrier d wwac m Policy No. WG�ti�1n�lS�ti4� Xb � IXD COFIr c'" F E;�33�iN"Ir�i7f:'1'�w?R :3�,'+7,�786,�iLt
ob O �'R.I. ,AT15 11 4�i4>�S?LWT.Ga3aty
Q (This section need not be completed if the permit valuation is for$100.00 or less).
OljISTR'I'C::�lON��°UF 101_000_{18_000 s},3nso
_J ( ) I certify that in the performance of the work for which this permit is issued, Pdra&Pd
I shall not employ any person in any manner so as to become subject to the ME,tNIA MICAL r,f 101.000.421-000 022100
workers' compensation laws of California, and agree that if I should become irLW7TRICAL M. I0;-WO.470-000 $3it'l.i9
3 subject to the workers' compensation provisions of Section 3700 of the Labor PyaNWING IEE 10 1,r}e11,04 9,-000 t3KSO
Code, I shall forthwith comply with those provisions. ;T3ti1AI�f Api1'D`It2sl I• S•MID 1f11-4"asfl-"'�5`!
Date: + Applicant t "°"w~
-' C3��t(a1J11+I4IFER If7l-JC 3w4 3=S3Y21 13.t1�
1111111 Warning: Failure to secure Workers'Compensation coverage is unlawful and DEVE..C1PM IltirP CT 1sT:(, I QIp,CO
shall subject an employer to criminal penalties and civil fines up to$100,000,in Am,N Punic ii.A s lil;•sIL V0.00OA4.5-000 530,47
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
"4 application.
1.Each person upon whose behalf this application is made&each person at 7A;"��� ;:. C3bi� ?fx�:'.1°JG)1�AW'D PLAN*C.7(:F?C:-K $1 sa,5^1�•�t9`
whose request and for whose benefit work is performed under Or pursuant to II� n EsW Pt`.0 PAa"1.'•�?T Ell] �Cti,C'0
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. i PERM'L•F1IRG MTE NOW
2.Any permit issued as a result of this application becomes null and void if AUG,()work is not commenced within 180 days from date of issuance of such AG 1 2003
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 CI i`t C:L9{''VITA f I IIIIIII VIII (II IIII 74
• 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 IE
the above-mentioned property for inspection purposes.
RECEIPT
Date DATE BY DATE FINALED INSPECTO
Signature (Owner/Agent) "- ~��- -�~~ r �• q; r ; ,- =' 1 /� 2 U
INSPECTION RECORD
OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR
BUILDING APPROVALS MECHANICAL APPROVALS
Set Backs Underground Ducts
Forms&Footings — Ducts N—
Slab Grade z Return Air .y-- 4— y
Steel —/7, Combustion Air
Roof Deck 3 _ Exhaust Fans
O.K.to Wrap 3— 3t9..y F.A.U.
Framing - q- Compressor
Insulation Vents
Fireplace P.L. Grills
Fireplace T.O. Fans&Controls
Party Wall Insulation Condensate Lines
Party Wall Firewall +
Exterior Lath _Z o —y
Drywall-Int.Lath /
SAC .J -41 1
Final Q v
Final /2.- 'D7 POOLS - SPAS
BLOCKWALL APPROVALS Steel
Set Backs Electric Bond
Footings Main Drain
Bond Beam Approval to Cover
Equipment Location
Underground Electric
Underground Pibg.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 P— Pool Cover
Sewer Connection a- Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice(Gas)
ELECTRICAL A ROVALS
Temp.Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp.Use of Power
Final
Utility Notice(Perm)
4.
II��IIIIIIIIIIIIIIIIIIIII 75 ,
_ . ...
IE �
-a- � � Certifica to of Odcupan
.
INZWORATM
of � Building & Safety Department
I ' 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 F
construction and/or use.
BUILDING ADDRESS: 78-875 AVENUE 47 BLDG . C
Use classification: M.F.D. Building Permit No.: 0307-200 ..
Occupancy Group: R-1 Type of Construction: 'V-N Land Use Zone: MDR.
i
Owner of Building: SCPH Address: 516 BURCHETT STREET
} City, ST, ZIP: GLENDALE CA 91203
3
By: G. SHOWALTER
r Date: 12/27/04
13kiliding Officla
POST IN A CONSPICUOUS PLACE
o