SFD (0005-092)LICENSED 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 License is in full force and effect.
License # Lic. Class Exp. Date
478689 13 d2.°w�,E2C
ate' �- 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 DECLARATIOW
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 performanceA,of the work for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Policy No.
carnvr 00WEN RAOLI NWC $47!'01400
(This section need not be completed if hermit 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 thatifI should become
s,ubject to the workers' compensation provisions of Section 3700 of the Labor
,Code, I shall forthwith comply with those provisions.
Date: � "1' � c�;r:..� ApplicantG'
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 inspection purposes.
),Signature (Owner/Agent)_ '1jT_ t_k. " `"�'-` Date
"TOU BUILDING PERMIT PERMIT# --
ct�155-m-
DATE VALUATI LOT , TRACT
JOBS E�p�
ADDRESS � L�r%i 2: j
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
So"UrHER T IDLIS 1w,
P_ C. HOBBS dba SOTJ7HMN B111,3, LLC
14301; c v AN AVE sTL? 100
55.960 PGABLVD
ORA1< O CA _836
LA WA CA 92253 t
(714)633-7260 Ck3Lft 5487
USE OF PERMIT
'% .IVA '
rAf » I.CiT i.�iN :3.A+Ca!dtx PERMIT DORS NOT DICLUDIR, I•II=X
1 017 /p
CUSTOM CONSTRUCTION 4;506,00 SI'
PORCIi/PATIO 1,544.00 SF
OARAGEMARPOR.`P (OF) 14;M.40
XS'T`3.1 IX.. COST OF COX M- UCMC N
�i3f►, i00
MAW YJ%Z SM04ARY
CONSTRUCTION IEE 101,1000-418.000 $1,644.00
PLAN CHECK Fft," 101-000439-318 $1,315.41
MECHANICAL FEL 101.000.421.000 $115.50
ELECTRICAL. P E 101-000-A.20-000 $2a a9
PLUNRIBINO FIS 101.000.419.000 $219.00
STRONO MOTION FEE - RESID 101-000-241-000 $33.63
GRADING +,+E 101.0010-423.000 $20.00
DEVELOPER IMPACT FFZ $I,9 no
AIT IN PUBLIC PLACM -,RE-31[ 701.000.255.000 1463, 3
FEE DEPOSIT 101-000-8439-318 •$1,000.00
SH YB-'T1YY1 L COX8TK(Jt 12t. X AND PLA'l+a' t'`I RCK
$3,950.66
LESS PRE -PAM', M `3
41,000.00
TOTAL MOW= FEES P13F. NOW
l
RECEIPT
DATE
ABY%
DATE F AL ��
ts
I P R
f�1 �•,
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
11
Underground Ducts
Forms & Footings d�
p$
Ducts
Slab Grade
_
Return Air
Steel
Combustion Air
Roof Deck k kis 141
Exhaust Fans
O.K to WrErp
F.A.U.
Framing 0ILT7 _ L
_
/iJ
Compressor
Insulationf
�`z
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
%PC. _ _
vinal
BLOCKWALL APPROV LS
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 APPR VALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
���
Encapsulation
Gas Piping
1/7
Gas Test
Appliances
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
Utility Notice (Perm)
Final
COMMENTS:
Y
Certificate -of Occupancy.�-
City ;of L,a Quinta
Building and Safety Department oFti°
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
-0f the City regulating building construction or use. For the following:
BUILDING ADDRESS:` 81=095 NATIONAL
Use Classification: SINGLE FAMILY DWELLING . Bldg. Permit No.:. 0005-092 J
Occupancy Group: R-3• Type of Construction: VN Land ,Use Zone: RL
Owner of Building: SOUTHERN HILLS LLC Address: 1430 E'CHAPMAN AVE STE 100
City: ORANGE, CA 92886
By: DANIEL P. CRAWFORD JR.
Date: 12/24/02
Building Official '
POST IN A CONSPICUOUS PLACE '