0307-204 (MFD) LICENSED CONTRACTOR DECLARATIONI I T j (}03074M « ;
` PERMIT# a
I hereby affirm under penalty of..perjury that I am licensed under provisions of BUILDING PERM� � "
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and q� r
U) , DATE VALUATION ' 'vY�i�1y ��.t`{ LOT 'LgS' TRACT LXr
c4 U.I Professionals Code,and my License is in full force and effect.
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O � ch License# Lic.Class � Exp.Date a F �
r. Cy LO I F,,%5_`,4II E%C-.8 M r '7131/03. JOB SITE 7"75 A.11MMM 4'1t,Ci�Ia'�,�G.E.. APN
Lu r ADDRESS D
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Z r- Date c,i f ) i%��'_�>Signature.of Contracto�'�-•- - ;-•--•• ""- � � OWNER. CONTRACTOR/DESIGNER/EN (NEER
O.� Z LL- 1`1. SCPH RO"'CIMMRM,3110K CO.,`lie.
r- ~ C OWNER-BUILDER DECLARATION �, , 1 + > c
� U �I6,Z3VIR.. ?�'T STk' ;.l' 78�!�'0I I�tCi�:1.�.,�,�, 1110 ]'di.)��i��C.f��a..5
LU a I hereby affirm under penalty of perjury that I am exempt from the Contractor's [¢ {ip els,;,% Cf '4w t. 2��Ai* `7 CkJ + e,1?5 It
U) License Law for the following reason: . I;eD] ���� �t1�'1 «'687
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
contractors to construct the project (Sec. 7044, Business & Professionals ; ,,,�„ ,,;x.,,,„,t ,�,�,,,,r>,, rr n•r.•i t,
Code). I `:•';�.; „':'y';.:..Hu:: :<,,,F., •.,..' : ::::�:. „ ......
C () I am exempt under Section B&P.C.for this reason €'1%"I'T DOM 140T MI?iDE:F.°x c�t",'�:V%011111-sl OR 4F006.
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N' Date Signature, of`Owner I
rn
d Z WORKER'S COMPENSATION DECLARATION
oZ I hereby affirm under penalty of perjury one of the following declarations: ;dPBKi�IIt ; 1 , i SIr
LO H O O 1 have and will maintain a certificate of consent to self-insure for workers' A/C•«GfYMNIXJdf,EAX S?
.X W compensation, as provided for by Section 3700 of the Labor Code, for the LjOWRA,CT ALS.vtiUriJ't 29u,442.00 LO
m -1 Q performance of the work for which this permit is issued.
Q (� ( /)` I have and will maintain workers'compensation insurance,as required by
O Q Section 3700 of the Labor Code, for the performance of the work for which this
rn F— permit is issued. My workers' compensation insurance carrr`�ler &_Doug .no. are:
Z Carrierxr,, rtrc• DJ. Policy Nb. �VC�3t,.'6�'3y0€' . 1 :3Fa t , ` 'e'.7F£:OROrf' . b.7': 6, 16:
ob a -
Q (This section need not be completed if the permit valuation is for$100.00 or less). CON59'.RUCI ON''`T"E 10” MYO.413 8_00n 31Az,1
J ( ) I certify that in the performance of the work for which this permit is issued, PLAN^.Ha R, 1 U1-0010-439-3 18 $1>tt'T t
I shall not employ any person in any manner so as to become subject to thetl'f`FYA3`tit';rid"FRE 1- >-vJ€"-4I^O(3C '`€s:CID
workers' compensation laws of California, and agree that if I should become
3 subject to the workers' compensation provisions of Section 3700 of the LaborFj+f:nI Q1t 0.00-419>-%10 $301
Code, I shall forthwith comply with those provisions. .�>tjlfiT?l� j
Date: I . ApplicantFt, int Fk - t�i�e+Y3 ''9.L?I €rw�x�;r�I-�30f1
(3 ' iTA2Ic1)EIi101*lr�t3u3a&iJGO a1�i,l1U '
Warning: Failure to secure Workers' Compensation coverage is unlawful and ]D*TVM..0 PX11IMPAC:1'FEZ $12,t)f4b•9 '
shall subject an employer to criminal penalties and civil fines up to$100,000,inPLAAR
F 1 ,.1�tT.BI A1C:. ,4 <<< �'7 � 7 «<,`,4.5«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 y <
for a permit subject to the conditions and restrictions set forth on his F: ti
application.
1.Each person upon whose behalf this application is made&each person at' / `5-A � f �~ ' +
whose request and for whose benefit work is performed under or pursuantto" /� �. FIR:Rv FAID
any permit issued as a result of this applicator agrees to,&shall,•indemnify_
& hold harmless the City of La Quinta, its officers, agents and employees. a ;+UhA. §p .�1ii}ir,�•O1,'� �;
2.Any.permit issued as a result of this application becomes null and void if l��� 0 1 ��QJ
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. C}U.OF>!A,QfhlTA .
I certify that I have read this application and state that-the above information is Fir-aP CE DEPT IIIIIIIIIIIIIIIIIIIIIIIII
correct. I agree to comply with all City; and State laws relating to the building 77
construction, and hereby authorize representatives of this City to enter upon 7 IE
the above-mentioned property for inspection purposes: u. --
( RECEIPT DATE BY.
Date
FINALED INSPECTOR
Signature (Own er/Agent).^ ••• ! v
�• Date �?�f f t).� �,• ,°•l' .� /^''��:r
h
F INSPECTION RECORD
OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR
BUILDING APPROVALS MECHANICAL APPROVALS
Set Backs Underground Ducts
Forms&Footings 3- Ducts
Slab Grade - Return Air
Steel 3 -,Z-.) Combustion Air
Roof Deck 5 Exhaust Fans
O.K.to Wrap D F.A.U.
Framing 5,— / Compressor
Insulation Vents
Fireplace P.L. Grills
Fireplace T.O. Fans&Controls
Party Wall Insulation Condensate Lines
Party Wall Firewall
Exterior Lath 6, - -
Drywall-Int.Lath y
Final
Final POOLS - SPAS
BLOCKWALr 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 _ ZZ_ Heater Final
Water Piping Plumbing Final
Plumbing Top Out Equipment Enclosure
Shower Pans O.K.for Finish Plaster
Sewer Lateral Pool Cover
Sewer Connection 3 Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice(Gas)
ELECTRICAL APP OVALS
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)
c.:
Certificate of 0ccupanc
Y
IrrcaaronnTsn�'�
9w5 in & Safet Department
OF T Budd g Y p
p
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 #E
Use classification: M.F.D. Building Permit No.:. 0307-204
Occupancy Group: R-1 Type of Construction: V-N Land Use Zone:. MFD
x
Owner of Building: SCPH Address: 516 BURCHETT STREET
City, ST, ZIP: GLENDALE CA 91203
By: G.SHOWALTER
r F .
dt� Date: 12/30/04
Building Official
POST IN A CONSPICUOUS PLACE