SFD (0111-181)°" LICENSED CONTRACTOR DECLARATION
I her, Dy 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
r
{ /�
Dat ' ! 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:
( ) 1, as owner of the property, cr my employees with wages as their solea
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). ' ''t ,
() I am exempt under Section' B&P.C. for this reason
Date Signature of Owner
•r
,,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:
Carrier Policy No.
offwrl FUND
(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,
.l 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 prov ons of Section,3700'f the Labor
Code, I shall fortith
h comply with those provislons. r�rr
rr
Date:: r <; Applicant -✓ j
Warning: Failure to secure Workers' mpensation 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 fortes 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 insppdtidn purpos.e . f
Signature (Owner/Agen j °if Dae
BUILDING PERMIT PERMIT#
DATE VALUATION LOT r f� A" TRACT
JOB SITE."
APN
ADDRESS .� s. fi��C�.i� ��i:�/F.��ia:��J,h3�.
�f+����.,�.��•^��t�b
OWNER
CONTRACTOR/DESIGNER/EN 1NEER
'. '1}1+ T 'A't��`'�. LVPMXN'1'
S1�.€�MS .�.'Oi�•I3'�'Ri;fi>�, �iIC7R.N
PG Do x 17 16
79.29-5t. CY30IJA, C7MWfAD.R.
LA QUWTA (4A 92233
L-A Q TA CA 92253
(760,)771 -1941 0191 1 2996
USE OF PERMIT
ff.%8G'LEXrA1f;�.YDWEL L4 G
WD m i', UI' i4 Pf., V 91, pXRNIT Doer NoT mC1..23,m WxWx wA.L.D,
JP001.,, dPA;. R DTtiVFONA.YAPPROACH
CUSTOM C011nRUCTION 2�635100 OF
GARAORWARPOIrt 9F
ES,MATED Q06T OF i:(,ri�d'.�RU(7J"X0
220�XJK152"
sumwupv
L OMITRtiCTION RX 101.000-4] 8-000 slpno
PLAIN CHECK PEE, 1,01-00014 39-:518 $21190
ML^:M,•NIC-A.il FRE 101-000-421-:000 $105,00
01
PIXIM,0I 5( FEE 101.000-419$000 $1712:5
M(}1d0 A+it3'3'ION FSE -LEST 101--000-241-00.0 Map
ORA.fANO FEE 101-000-423.00)
D -11V l.A.)PL?K JMP.ACiT YZE $1,907.00
ART N KINX PLACER REM TIM00-44-5-000 $52, a 3
x.
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SUB -TOTAL CONMt: M10K AND PLANCEMCF,
VX838
UM3 P:(M=PAW I%1%'
$0;010
RECEIPT
DATE
B,(
DATE FI ALED
INSPECTOR
Co P T 60 �d,. ....
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
_ _j_I
/ `�
Ducts
- —,?
Slab Grade
_
���—
Return Air
_
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. Wrap
Framing
�L— _
Compressor
_�
'Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
_�
Fans & Controls
Party Wall Insulation
Condensate Lines
ZZ
Party Wall Firewall
Exterior Lath
tf_
Drywall -Int. Lath
�/—
Final
-
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
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
ZZ �( /
�o
Heater Final
Water Piping
U
Plumbing Final
Plumbing Top Out
_
�Z _ 2
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
_ _ _
Z Z� j ����
Pool Cover
Encapsulation
Gas Piping
Gas Test.
_
-
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
!f _
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
7d
Utility Notice (Perm)
o T
a
C f Odcupana
City ofla Qpinta.�-
Building
and Safety Department...
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.comp/iance with the various ordinances
of the City regulating building construction or use. For the following:
BUILDING ADDRESS:, 79-544 MISSION DRIVE -EAST
Use Classification:' SINGLE FAMILY DWELLING Bldg. Permit No.: 0111-181
'Occupancy Group: R-3 Type of Construction: V -N Land Use Zone: RL
• .Owner. of Building: TD DESERT DEVELOPMENT Address: PO BOX 1716
City:. LA QUINTA CA. 92253
By: GARY SHOWALTER
—!dam Date: 07-16-02
Building Official
POST IN A CONSPICUOUS PLACE