0307-201 (MFD) LICENSED CONTRACTOR DECLARATION PERMIT#
U) I hereby affirm under.,penalty of perjury that I am licensed under provisions of BUILDING PERMIT 0110_201
I— Chapter 9 (commencing with Section 7000)of Division 3 of the Business and DATE VALUATIONLOT 2'x.5 TRACT
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LLI Professionals Code,and my License is in full force and effect. f�
p =) M License# Lic.Class Exp.Date '
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D 0.',-8.MC W3 A;.'., JOB SITE ADDRESS �8-075�'i�a'3"!:�1UEA7,DLT,,(;'.(3. JAPN
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� Z r-- DaSignature of Contractor 1�rOWNER CONTRACTOR/DESIGNER/EN INEER
O o-., `�i `'' �3(:.Pu`S :i3 ,i:Cil7a�lCt�L xZC�P•Y + .,.fAf%.
OWNER-BUILDER DECLARATION 5�+
_J U r- 51 f-AUR ,'HUMT:• �.L 1's": '�9"4411 MIG�H AY 13 1 05 LA,42UIx•i.rA 17LN 97,E
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I hereby affirm under penalty of perjury that I am exempt from the Contractor'sC};�c� "��p j�(t CA. 91 Z03 sj,KDMIGY"') Cps _92138-017
U) License Law for the following reason: 61s?f1`�T•�'15 ,� �
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
( ) 1, as owner of the property, am exclusively contracting with licensed NiT,1 .71-:F.1LMEUK.WWKII G
contractors to construct the project (Sec. 7044, Business & Professionals _
Code). tam ..~ ..i!A J9 i'Z. fZ,! "uva.y a o ac
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() I am exempt under Section B&P.C.for this reason t11a1i:1 YK]k >1d1A i`�3 HIMIT I?fmc. im I?r1t`.I.ii1.51 iaLo `.x vvv xuj Ott
O N Date Signature of Owner RF. UCFD,?S.E PZRMI T OF"C".
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CL Q WORKER'S COMPENSATION DECLARATION
C:) Z I hereby affirm under penalty of perjury one of the following declarations: T'h:13�k ,w:
p O 1 have and will maintain a certificate of consent to self-insure for workers' AsZ„.C"0.4-M,ERC"FAL E,Qx3,ao 5i -
X W compensation, as provided for by Section 3700 of the Labor Code, for the t''ONTbUS AMOUNT T 6.$G 41
O J Q performance of the work for which this permit is issued.
C0 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
tl LO H permit is issued. My workers' compensation insurance carrier & policy no. are:
Z Carrier zone;:M'iA&i.CW Policy No. +{;014616619.90 5.fiet"7mmim C'aS".f'(AF Cows;'Y'kt.L.Tr"T'Ct;w 347,7MAO
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Q (This section need not be completed if the permit valuation is for$100.00 or less). CONSTRUCT1014 3'1.1? 101.-M-418,11", 91,!.1n5D
--t ( ) I certify that in the performance of the work for which this permit is issued, PILA'II C Ht?A «"K7 101,-D00-421,9-3 18 t-3+53?
1 shall not employ any person in any manner so as to become subject to the MECHANICAL Pb•,t7 101.OGC- 121^1305 ti322.0$
workers' compensation laws of California, and agree that if I should become Mial fPUCAf•,,7h;� $307.19
subject to the workers'compensation provisions of Section 3700 of the Labor PI.t3M19140 FIT 101.000.419.00 S Q9011 so
Code, I shall forthwith comply with those provisions. „r w�,, STRC1140 MOT10 1 PEZ-14i SIS 103-000.2412 000
Date: - LApplicant
N GRAI 1140'PIT, 101.000-423-000
Warning: Failure to secure Workers'Compensation coverage is unlawful and 13Ln!F2r11YF1P1.
shall subject an employer to criminal penalties and civil fines up to$100,000,in ART IN 7,1363,.1(:F°1.WW ES-RESIL 270'000-445.000
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. i � / I I-N
1. Each person upon whose behalf this application is made&each person at �� C04d:i'TQt 7�:'rio"f•taf�l1f :F';P,`J C�'1* ?6YS,��'3b•¢3
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, indemnity 1 (1 IUl
& hold harmless the City of La Quinta, its officers, agents and employees. ! 'AUG 1 ��u � "8 DT'117OW Ya .
2.Any permit issued as a result of this application becomes null and void if
149683
work is not commenced within 180 days from date of issuance of such C--
permit,
-permit, or cessation of work for 180 days will subject permit to cancellation. " , "'_?7 - -�
I certify that I have read this application and state that the above information is IIIIIIIIIIIIIII�IIIIIIIII79
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. y
4, RECEIPT DATE BY DATE INALED INSPECTO
Signature (Owner/Agent)��� — - • ~" Dates
INSPECTION RECORD
OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR
BUILDING APPROVALS MECHANICAL APPROVALS
Set Backs Underground Ducts
Forms&Footings Ducts
Slab Grade Return Air
Steel Combustion Air
Roof Deck Exhaust Fans
O.K to Wrap 6 -.3 o 4 7 F.A.U.
Framing Compressor
Insulation <p / — Vents
Fireplace P.L. Grills
Fireplace T.O. Fans&Controls
Party Wall Insulation Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall-Int.Lath
Final •�3
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 Pool Cover
Sewer ConnectionEncapsulation
Gas Piping '
Gas Test
Appliances
Final
COMMENTS:
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 SOZ
Temp.Use of Power
Final
Utility Notice(Perm)
i
Certificatep of Occu ancY
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G �w� Buildin & SafetyDepartment
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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 #G'
Use classification: R-1 Building Permit No.: 0307-201
Occupancy Group: MFD Type of Construction: V-N Land Use Zone: MFD
� i
Owner of Building: SCPH
Address: 516 BURCHETT STREET
City, ST, ZIP: GLENDALE CA 91203
By: G.SHOWALTER
s . r
Date: 01/03/05
Building Official
POST IN A CONSPICUOUS PLACE