0307-205 (MFD) I _ ,
LICENSED CONTRACTOR DECLARATION
N I hereby affirm under penalty of perjury that I am licensed under provisions of BUILDING PERMIT PERM' S
H Chapter 9 (commencing with Section 7000)of Division 3 of the Business and DATE VALUATION ?r'. ,,g'.r LOT �` '� TRACT
c4 W Professionals Code,and my License is in full force and effect. t- fr" ` �'�
License# Lic.Class Exp.Date
O � c'o -
r i d � X:Q; : C:•�.1 FUM �"k JOB SITE ADDRESS
-fY`�.�/�'V:9.S I F.47-BLID G.,1 APN
c, �•IrZ I= N �' OWNER , CONTRACTOR/DESIGNER/EN &NEER
Z r` �Date� Signature of Contractor i
� O �* �._ .8011114 1'0 U.C:' )MITT,RUC'T ON Ccs.,ilk C
J UCID OWNER-BUILDER DECLARATION .5 16 D(Mo MT k MA-Z r 77-401 MCAMNY 3 1105 ld,.k QC>ATA CA 97;.53
U W I hereby affirm under penalty of perjury that I am exempt from the Contractor's CT(.1�.�.ALL 01..fi. V i Vit SAN U ,0 CX
~ N License Law for the following reason: p
Z ( ) I, as owner of the property, or my employees with wages as their sole
(b'aSfj�.t:Y r 71.e�s ��� � 1Y�
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 l `d:j'ii-k t..AMy DiSJ.- LINE}
contractors to construct the project (Sec. 7044, Business & Professionals
Code). _ttXf JAY 0.244 1 i%V s sr •a.+x.�i1NT.•i � 1 !4 1 i}:e v Y'i Jl rµa•a �:r�lJ.
C'') () I am exempt under Section , B&P.C.for this reason PRRMS1'DOES NOT ULOC Kr 'NN.ALAZ OR.POOL,
LO
N Date Signature of Owner
ON
Q)
ZWORKER'S COMPENSATION DECLARATION
C:) Q Z I hereby affirm under penalty of perjury one of the following declarations: .Pl�s1?7K. . 3,74,A.1;1 OF
U-) ~ O O 1 have and will maintain a certificate of consent to self-insure for workers' VC..4'�f�,i E1 �s1 5,:45,c3,?sr
X U compensation, as provided for by Section 3700 of the Labor Code, for the C!ON'd'K&C T AXoDU;N T 2)6,,442.W 1,8
O J Q performance of the work for which this permit is issued.
Cal Q () 0116 1 have and will maintain workers'compensation insurance, as required by
O UQ Section 3700 of the Labor Code, for the performance of the work for which this
LO H permit is issued. My workers' compensation insurance carrier &..policy no. are:
NT Z Carrier =i&' ra.s�r s� Policy No. C36'010b
Q (This section need not be completed if the permit valuation is for$100.00 or less). CC) N�s7tiG`t`JU?1 ^ i1�J+"E Cis 1 Es"l)Uf3 �1°AS�!'kfd
J ( ) I certify that in the performance of the work for which this permit is issued, PLAN CJ•1'Il".:K FEE 101-04.i'.) 3*n"318 s1,S%.34
I shall not employ any person in any manner so as to become subject to the MZtS!-1.WIHC„A.FEE I I'M"iD00-4'Z)-000 3463.30
workers' compensation laws of California, and agree that if I should become Et,1'C`1'1 I(Wk,FEE- "0'-0 t',.A'20-000 $29x.33 .
3 subject to,the workers' compensation provisions of Section 3700 of the Labor 13LUM'f}NO MT I01,,U;�,C,419_000 %348,'1
Code, I shall forthwith comply with those provisions.
,,,
.Date: i a 1 Applicant ,� ?f'•.Cy1' O IASGiTIOW F11.21=1�,ES1A 101-G1`J;:-20-(Di D
O12.ADINS}F1~.E 0 0r 1!3-(Ky.'X1 SIM
Warning: Failure to secure Workers'Compensation coverage is unlawful and I7'LVELOPFT;1MFAVA,ME wr1,3tN oo
shall subject an employer to criminal penalties and civil fines up to$100,000,in , ,.,� i. r
addition to the cost of compensation,damages as provided for in Section 3706 ART'rZ PET�f ,1..Pt"� `SiL �!()"�1C>U-9:4J (3CjUi ( ,`fil
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 f� 'P-7:Y3TAI,CO.�'>R'1�•�71;=z .aT�F+2�x:9 T'l rahl'�"f�i�.�;A'. $13,076.66
whose request and for whose benefit work is performed under or pursuant to 1cul 1! .3411.K3 PRI."PAM FIE'lis
1
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. ��' TO, ,f 111{0111 1ITM3 MT M)w
2.Any permit issued as a result of this application becomes null and void if ,r
work is not commenced within 180 days from date of issuance of such UJ 01 eC�03
permit, or cessation of work for 180 days will subject permit to cancellation.
application and state that the above information is 01
` r IIIIIIIIIIIIIIIIIIIIIIIII
I certify that I have read this a r_, �c:...;1;;, ,
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 BY DATE INALED INSPECT
,�,•Signature (Owner/Agent)i: - w ., `" Date ) \ °:i j >-• �(_<:'� -';; ���_
� t
INSPECTION RECORD
OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR
BUILDING APPROVALS MECHANICAL APPROVALS
Set Backs Underground Ducts
Forms&Footings 3-7, -y Ducts
Slab Grade a-.e-Y -- Return Air
Steel 3 •/ Combustion Air
Roof Deck .y- Exhaust Fans
O.K to Wrap F.A.U.
Framing / - 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
S -
Final
Final `c7 - D t7 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 mr - Heater Final
Water Piping Plumbing Final
Plumbing Top Out Equipment Enclosure
Shower Pans i O.K.for Finish Plaster
Sewer Lateral _ c 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
Law Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp.Use of Power
Final
Utility Notice(Perm)
Certificate of Occupancy
; � IvaowoanTsn ��
OF g Y p Building & Safety Department
F
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 AVENUE47 BLDG #
Use classification: -R-1 Building Permit No.: 0307-205
Occupancy Group: MFD Type of Construction: V-N Land Use Zone: R-L
i Owner of Building: SCPH Address: 516 BURCHETT STREET
E
City, ST, ZIP: GLENDALE CA 91203
�.. .• By: G. SHOWALTER
Date: 01/05/05
Building Official
y
POST IN A CONSPICUOUS PLACE. 9$