SFD (9907-333)LICENSED CONTRACTOR DECLARATION
•hereby 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 -
Date tr„ e f 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
sale (Sec: 7044, Business & Professionals Code).
( ) 1, as owner of the -property, am exclusively contracting with licensed
contractors to construct tfie, 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
ection 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:
CarrierPolicy No.
qq+ AA T11,, aqyp R ^)� ♦ 1
(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 shall forthwith comply with those p gni ions.
Date: 4, , fa? Applicant—
Warning:
pplicant '"--
.;, .. 'as, , , ,•:, jar �,..� ,-. _,.- .. _ .'
Warning: Failure to secure Workers' 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 inspection purposes.
Signature (Owner/Agent) Date
BUILDING. P.-t-AMIT + PERMIT# F
TE VALUATION LOT g� TRACT
JOB SITE
ADDRESS
APN ;
OWNER
CONTRACTOR/DESIGNER/EN (NEER
DC0 DINEWPUMT, .WC;
Lim) DEI OPMann" WC
78"60 MC714- AY 11,1
761-600 Hic-11*2WA Y.
,LQZ�A (,A 922S
LA QUWTA CA225
(76, 0771-12 745 MIA 11 u0
USE OF PERMIT
BURGLE. RAW.,YDWELLT.§ G
SPO - LOT 59 PL.e5A14 :3 PERMIT M- M) V.2C3.,7:tLiE HL OC9 WALJJP 0L
OR ,APPROACH DRY.VYWAY.
'kRACT t`ONSTlie.UCTION %097,00 U
PORCT':t>'1r'dt VO '124.40 S.?
€ tARA.iraCwtPORT,Lai+f
C. 0,9'iOF C;OMi .': UC.(tION
gEeS71MM
i:'.70a�Y.A�'YA.4, DJ4Ainf1, i'J 6.7J1td31S.7Y
.'
t 0133 111,�1!r'1 0.� 1.01.000.418.000 =00
PIAN CHECK PVE S609.16
h=11".#i1'liQAILIM,; 101.000.421.000 $66,50
n,%CYWCA.L F1981 '101-000-420-000 4130.90
PiGUMST1130 TOFF, 101-600-419-000 $160.100
iT t NO Md; T]ON PEE-141r,°3.YD 1.01-000-241-000 V I A3
rLr +►f�Td�i � 101-000-42.3-000
ART PUBLIC: PLsAC99- R01r.701.000.255»M *60,04
" T3'G'i'lM KIRD PUS CNUIR.
$3,6593,8:1
: l X3 :f:'UPPAID 14103
$0.00
JUN 1 3 2001
D Y rFX8 DUE HO -
CITY OF TA aUINTA
FINANCE DEPT
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION`'
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs _
Forms & Footings z
Slab Grade -�
Steel
Roof Deck 83/0 / !x�
O.K. to WrapF.A.U.
Framing� Z.%o_�
/p — y/' (/(
Insulation � ZZ
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
Compressor
Vents
Fireplace P.L.
_
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final /�, ��5of
BLOCKWALL APPROVALS
Final
POOLS - SPAS
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
7
Waste Lines _d��
Water Piping
Gas Test
Electric Final
Heater Final
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
`
S��/ ��
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final _ y d/'alfS
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)
Certificate of Occupancy
'CitV of LaQuintd
Building andSafet DeDartmdnt��� y OI:� •
This Certificate issued pursuant to the requirements of Section 109 of the Uniform Building Code,
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 following:
1
BUILDING ADDRESS: 79-770 MIRAFLORES BOULEVARD
r ,
Use Classification: SINGLE FAMILY DWELLING Bldg. Permit No.: 9907-333
Occupancy Group: R-3 Type of Construction: VN Land Use Zone: CR
Owner of Building: DCD DEVELOPMENT, INC. Address: 78-600 HIGHWAY 111 '
City: LA QUINTA; CA 92253
_ By: GARY SHOWALTER
Date: December 28, 2001
Building Official `
r- POST IN A CONSPICUOUS PLACE