SFD (9907-332)' LICENSED CONTRACTOR DECLARATION
I +Ffereby-affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
7C a� 14 Cs MC 43��'9�. t"
Date Signature of Contractor
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
Gale (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.
�)'T 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:
Cartier Policy No.
ST.AITE I?U D 1663016.01:
(This section need not be completed 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 provisions of Section 3700 of the Labor
Code, I sh II forthwith comply with those Prov sions.
Date: _ a <z Applicants+
Warning: Failure to secure Workers', Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
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.
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 all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for nspection purposes.
Signature Owner/A ent��
9 ( 9 ) Date
BUILDING PERMIT PERMIT#
DATE/ VALUATION LOT TRACT
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OWNER
CONTRACTOR/ DESIGNER/ EN INEER
rcD D:y"VELOPIcaLI':t+�`t,.INC
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78.600 i-Ut"rHWAT III `
.0 f -l. q7,@'i'r6`,m (°A ' 92 253
Lf:%Qj. i'B',fi,, OA. 92,25
(760)771.3345 10h`�i. 5.4 2180
USE OF PERMIT
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3?0 • U)T 59 PLAAN X.-- PERMIT 000'NOT 1NC3.1.10F. Tt1.,C CK WA1,.L
I P001, OR AP1wRliPAWH MffF''d'e'. Y.,
TRACT C>iiTtSITRUCi`ION'r V
PORCIOPAiTIO IWe00 Sit
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1141"3)W
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CrJCYN..8TPUtwTI0H FE 101.000.418.000 9692.00
PLAN KvHW11:1}' 101-000-439-319 $581.19
MECHANICAL YER '101-000-4.21-000 U615 ►
URC RICA),, P72 101-000-4020-000, $123.15
P1s93'A5k INO FFE 101.000- 419.000 V".100
0ITROT40 MOTION YBE- RESID 10 1 -.000-24 1 -000
C9R A,•f. RIG Fite 101-000-423-000 $20,00
X}rEteE1..01'.eR IMPACT n $),907.00
AR't' 713 PUBL4C; EPLA.0 &, 7C `iOI�CYi7C)� �S�OifC1 3S%eft
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CITY OF LA OUINTA
FINANCE DEPT
0,594,62
RECEIPT
DATE,^ BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
_ _
Z —_
Underground Ducts
Ducts
Slab Grade
_
Retum Air
Steel
"ZZ
Combustion Air"
Roof Deck
��/d C
Exhaust Fans
O.K,to Wrap
Framing
"�2_ _ ��
�O `!!! !�/
�/
F.A.U.
Compressor
Insulation
_
�a
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
a '2yc
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
Waste Lines
_
1p/�
Electric Final
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral�j
(� 6
Pool Cover
SewerConnection
Encapsulation
Gas Piping
Gas Test
Appliances
Final '
COMMENTS:
Final
g_o
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)
2 _®/
1t I 1
Ceo f
ocd
upancy.,
City of La'Quinta
Building and Safety Depiartmont. OF
This Certificate issued pursuant ' to 'the requirements of Section 109 of the Uniform Building •Ciode, ►
certifying that, at the .time of issuance, this structure was in compliance with the various ordinances
of the City regulating building "construction or use. , For the follo win `
BUILDING ADDRESS: 79-780 MIRAFLORES BOULEVARD
Use Classification: SINGLE FAMILY DWELLING
Bldg. Permit No.: 9907-332
Occupancy'Group: R-3 Type of Construction: VN Land Use Zone: CR `
Owner of Building:, DCD DEVELOPMENT, INC., Address: ' 78-600 HIGHWAY 1 11
City: LA QUINTA, CA 92253
By,: GARY SHOWALTER
Date: ' December 28, 2001
Building Official
POST IN A CONSPICUOUS PLACE