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LICENSED CONTRACTOR DECLARATION
'I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 700Q) of Division 3 of the Business and
Professionals Code, and my License is ;hi full;fo`r-c and effect.
License #
,/ 736920
Bate ' 1
Lic. Class
Signature of Contractor
Exp. Date
0t/3)x'2(
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 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).
( ) I, as owner of the property, am exclusively contracting with licensed•
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
() I am exempt under Section , B&P.C. for this reason
Date • Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
( ) I have and will maintain a certificate of consent to self -insure for workers'
compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
\(,) I have and will maintain workers' compensation insurance, as required by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Canter Policy No.
'TATE FUND 2M40; -!gyp
(This section need not be c3mpleted if the permit valuation is for $100.00 or less).
(.) I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation:ptrovis1ons of Section 3700 of the Labor
Code„I shall forthwith comply with those ro`visions.
Date. --9 y Applicant tiR
1..
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil firies up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorneys 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
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, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
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.
I certify that I have read this application and state that the above information is
correct. I agree to comply with alljCity, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
th/e�above-mentioned property for inspection purposes.
Signature (Owner/Agent) !-- V��' Date --'7 71,A •
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 0103-18TRACT
JOB SITE
ADDRESS
45 AV .A AINArtAD()
APN
- -
OWNER
LA Qtal•T`A PROPERTIES
P., fa NM 134
LA. W OW/A. CA 92253
CONTRACTOR/DESIGNER/ENGINEER
C.ON171241PORARY HC.t .Es
5] 310 AV NI./A BERMUDAS
LAQXJIN'TA. CA. 92253
C? 60)564-1962 CB 6255
USE OF AFP�ERMIIT
yAL BU q 31I0
26 L. k°. X 4' .,MOH WALL t'C» PROPANE ENCLOSURE _ •OR.CO STANDARD
4 rt. . ll1 A?JL+
'lMAT D CO ? OF
ESTIMATED
P, EY]A7i TG�,hSVIARE
CONSTRUCTION N ITL 103-000-418-000
e
SUB -TOTAL COMM:.
TarA3:4P,remn
2o,w) IR
CON"IRUC1ION
$15.44
a
MAR 2 6 2001
CITY OF LA OUINTA
'. DM Remo;
r .7”"
:s
4161O
$13.00
$0.00
$15.,00
F,as PREP 3
ms DuE INTOW
101111 III
1111111 71
RECEIPT
DATE
BY / r�/
DATIINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Retum Air
Steel
Combustion Air
Roof Deck
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
Pa Wall Firewall
E prior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL
A PROVALS
772 6/
4/(// /
steel
Set Backs
S�
Electric Bond
Footings
tS.Yr
Main Drain
Approval to Cover
Equipment Location
Bond Beam
Underground Electric
Underground Plbg. Test
Final/,,25/�y
,Z7
Gas Piping
Gas Test
PLUMBING APPROVALS
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 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
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
11 111111111111 72
IE
RC DISTRICT - PLANNING REVIEW FORM
This form is to be used by CDD staff for review of single family dwellings in the RC (Cove Residential)
District, in order to determine the applicability of compatibility issues or need to require the filing of Master
Design Guidelines by the applicant. It shall be transmitted to the Building and Safety Department as your
correction list. Please attach additional explanations.as necessary.
APPLICANT CONTEMPORARY HOMES - Tnm Buf f in
SITE ADDRESS
APN
54-445 Ave a r? o V. #LVAL O
BINNO.: 24. CASENO.: 2000-324
LEGAL: LOT BLOCK UNIT S.C.@V.L.Q.
CHECKED BY:
Stan Sawa
DATE:
Inform the assigned Building plan checker upon your assignment to this case. The CDD Executive
Secretary maintains a log book to track applications and assign case numbers.
REQUIRED ITEM
Y
N
COMMENT/CORRECTION
Compatibility Review
Case logged and number assigned
Verify legal and APN information
Consistent with MDG on file (as.applicable
MDG filing required (5 filings since 9/3/98)
Consistency with street/surrounding area:
Colors
Materials
Architecture
\j
\
/�
Other Requirements: - I o
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