SFD (0111-184)j0 44CENSED CONTRACTOR DECLARATION
I 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 Li tense is in full force and effect.
License # Lic. Class Exp Date
Dated t t'D Slgnalure of Contractor
' 1
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).
( 4.) 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. ofthe 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 0.'T Policy No. Qk su�tl 9721
(This section need not be completed if the permit valuation is for $100.00 or less),
( ) I certify thaNn 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 j should become
subject to the'wor4 ers' co mpensatiog,pror'ris ns of Section *00 of the Labor
Code, I shall'forthwith comply with,those prov�isons.
Dater' 1'-% p .°I / Applicant
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 orpursuant 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.
12. 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 aA?rije representatives of this City to enter upoA
the above-mentioned propertytfor`inspection"purposes.A
Signature (Owner/Agent) .4 r , Date
BUILDING PERMIT. PERMIT #
DATE VALUATION LOT 0111484 TRACT
y 29457.2
JOB SITE
APN
ADDRESS. -«4 Iusnow Dmwiug '
649•yT%�"je'�.
OWNER
CONTRACTOR / DESIGNER / EN (NEER
IXID %rC3,�' i:�N".f
MIMICSCi-.7t1P�)s`��'IIRITtC'+�Fp�.�1���+�
���ppE'�.tt'�xy 7D,�.�
Po 80AIX i F 16
e� yq�}
19.2 5 ld4.wY..� c I- A �,),U .1V Sd"e.A✓.1t
(160)771.19.1.1 CBLO M- 6
USE OF PERMIT
.10D Y.C3!' 17 P1.01 F,2, P?2IT DO&S Wrr INCAUDE H1,WK'WAJJ ,
CUSTOM CONSTRUCTION .4924.00 3F
1'OPUIKIPA5,'1'ICD X33.00 fsp
0AI3.rItti31?K'.ARJ ORT4 ei1.(9 31"
e-WESTRUCTION FP„L 101 AWA -1 511133.00 '
PLAN CHECK MY. 101-000-439-318 1233.24
MKRMI IC"AL 17 Y 101 -00".21 -000 $130 SCS
F.LMTRICAL PAt 101-000--4,20.0€00 $169.7A
1'1liDmp,wo RE 1019000.419-000 915.1”
at,P, R WO W1'BON PER • RESI.D 101 -000-24.1 -OW $24.01
�' i�l it1 ✓� 101-000-423 -000 $20.00
tl70.i?�it+
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1'?l�ART
t'�;4,,Y%71y���Rp1lypf�.te`.�ITEPp r 7,70-000-445-000
p00q,F00M
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IUB-MIAIL Cc`.NVITIETC:E;ft7N AM 17.T.A9 (WICK.
03
'O'A3a PER M11WS DUN NOW
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RECEIPT
DATE F
f
BY f
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DA FINA l
- /G�
INSPECT
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INSPECTION RECORD
OPERATION
u DATE
I INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
Slab Grade
(- ^ ®2
- j / --aZ
_
Underground Ducts
Ducts✓f/-
Return Air
_
Steel
1 3 nZ
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
— _
-
Roof Deck L
O.K. to Wrap far _ g
Framing
Insulation y. �=
Fireplace P.L.
Grills
Fireplace T.O.
_
Fans & Controls
Condensate Lines
Party Wall Insulation G S
Party Wali Firewall
Exterior Lath i�-Z F -L
Drywall - Int. Lath
V✓�
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
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
/
Waste Linesvy-
WaterPiping � 6J �
Plumbing Top Out
Heater Final
Plumbing Final
Equipment Enclosure
Shower Pans
_
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
Gas Piping
Gas Test
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(((
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Pool Cover
Encapsulation
Appliances
Final
COMMENTS:
,
Final J� —
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 z�Z.
Utility Notice (Perm) v b
f Occupancy.
rt►f►cafe o0
Ce,
CofLa.Quinta►ty
fet De r-tment ��M OFti
Building and Sa y p a
Phis 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:
BUILDING ADDRESS: 79-556 MISSION DRIVE, EAST
Use Classification: SINGLE FAMILY DWELLING s . Bldg. Permit.No.:' 011-1-184
Occupancy Group: R3 Type -of 'Construction: VN Land Use,Zone: , RL
Owner of Building: TD DESERT DEVELOPMENT Address: P.O. BOX ,1716
"Cit LA QUINTA
By: GARY SHOWALTER., '
Date: 08/13/02
Building `Official.
'. .POST IN A,CONSPIC000S PLACE _