SFD (0301-106)LICENSED CONTRACTOR DECLARATION
I liereby 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
674074 B RIC,
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
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
S ction 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 STATE FUND Policy No. 046-11104-2003
g (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, andl agree hat if I should become
subject to the workers' compensation provisions of Section, 700 of the Labor
Code, I shall folrthwith comply with those` provisions.
Date: • �� ! �_ Applicant ` f
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
I for a permit subject to the conditions and restrictions set forth on Fris
application. ?'r.
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, indemnity
v & 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 p ru poses. ^.
4
Signature (Owner/Agent) t' Date,, .
BUILDING PERMIT PERMIT#
C930:1-i4}ti
DATE VALUATION 9220,052M LOT 51 TRACT "!2293
JOB SITE ADDRESS XW 11 `+rS�er5.0'X D XF'.
APN Oi9-M4*7
OWNER
CONTRACTOR/ DESIGNER/ ENGINEER
•
IL "DIRMER LWryry.iNEW11
-01PaRS C0I7`C11Jp
PO BOAC 1710
79.295 IMM10.1:. QTJIKA.=
3AQT,IWTA. C . 92253
LAQUINTA CA 92253
USE OF PERMIT
SPD, 1AYr 51, KAW1 Lai. .PLERMIT DOM NOT.114C.LUVE SL.00K
WA> LL,% jP00, LOSPA OR DRIVEWAY APPROACK.
CUSITOM f rt 110- `Y'R1ICTION 211635.00 SP
CON §101.UV,TION F9Is 101>000.4.18.000 $L06319P
PLA14 C HEICK M9 smii'161
MYCHAIRICIAL FEE, '101.000-421.000 $10.99
T LFX,TII's1CAL YZE 101 -MO -420-000 $162.ol
PLUM.I3rNo FL9 101-000-419.000 �M79129
�A".k'.0140AlOT111:ik3M+l=' ID 101.-000-241-000 '$.7".1.09
WIDINOFFE 101-.J1 -423.000 $15.
OL,4E-L-0PF,R IMPACT1 17FZ $X405.00
,. AWV 11H tzUB.61 F,1,A&0, S -31C 270.000.445-000 M.13
:a
` JobT "D I`"1V.01K
x48 5.oq[A
ISOM
lL3l3
JAN 2 9 2003zed 1Pf� � D : NOW
CITY OF LA QUiNTA
FINANCE VEPT
RECEIPT
DATE
�. ����y�
BY 3
€I/,j
DAT FIN LED
�/
INSPE
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 8 Footings -
Slab Grade zzReturn
Ducts
Air
_ _
3
Steel p -
Combustion Air
Roof Deck _ �
Exhaust Fans
O.K. to Wrap _ 3 - y
F.A.U.
Framing 3 _ Jr=1i
Compressor
Insulation - -
Vents
'
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath L l
Drywall - Int. Lath
Final
raZ, 7,)
Final /
BLOCKWALL APPROVALS
steel
POOLS - SPAS
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 Lines
Heater Final
Water Piping // %
Plumbing Top Out
Plumbing Final
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection - -
Encapsulation
Gas Piping
Gas Test
Appliances
Final
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 47,
Utility Notice (Perm) , / - 0
COMMENTS:
cv- Certificateof Occupancy
G 9w5
of Building & Safety Department
This Certificate is issued pursuant to the requirements of Section 109 of the California Building
Code, certifying that, at the time of issuance, this structure was in compliance with the
provisions of the Building Code and the various ordinances of the City regulating building
construction and/or use.
BUILDING ADDRESS: 79-358 MISSION DR. WEST
Use classification: S.F.D. Building Permit No.: 0301-106
Occupancy Group: R-3 Type of Construction: V -N Land Use Zone: R -L
Owner Of Building: TD DESERT DEVELOPMENT Address: PO BOX 81716
City, ST, ZIP: LA QUINTA CA 92253
By: G. SHOWALTER
---�-' Date: 06/15/04
Building Official
POST IN A CONSPICUOUS PLACE
_
C,