SFD (0101-067)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
4786S9 B
,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). Y
( ) 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, tion 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.
0301-1404 RA014? 11*0 ;14701401
(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, 1 shall forthwith comply with those provisions.
Date:_ - 4 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 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) ,f` ,� -- - ^• Date" `` - y P
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
JOB SITE
APN
ADDRESS
'761420-030
OWNER — —
CONTRACTOR/17 EN (NEER
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RYPY17az 11L 33477,
U. Q� WJ'A CA 92W
CS14 5418
USE OF PERMIT
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RECEIPT
DATE
BY` `„
DATE FINALE
I SPEC OR
,,,
J
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings ��
�� _ _
Underground Ducts
Ducts
Return Air
Slab Grade
2�
Steel
Roof Deck
/ �_
Combustion Air
Exhaust Fans
O.K. to Wrap`''Cf
F.A.U.
Framing
��
Compressor
Insulation
TTT�
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
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
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Heater Final
Waste Lines
_
�/
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection/ _
Pool Cover •
Encapsulation
Gas Piping
Gas Test
74-74
Appliances
Final
COMMENTS:
�QLBT /Z.f�i�(
Final
_
Utility Notice (Gas)
_ -
ELECTRICAL APPROVALSs
Temp. Power Pole
Underground Conduit
Rough Wiring
C�
Low Voltage Wiring
Fudures
Main Service
Sub Panels_
_
Exterior Receptacles
G.FJ.
Smoke Detectors
Temp. Use of Power
Final'
0 i
— — —
Utility Notice (Perm)
Certificate of Occupancy
City of La Quints'
Building and Safety Department OfT�49
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:
BUILDING ADDRESS: 81-175 NATIONAL DRIVE
Use Classification: SINGLE FAMILY DWELLING Bldg. Permit No:: 0101-067
Occupancy Group: R-3 Type of Construction: VN Land Use Zone: RL
Owner of Building: NORMAN ESTATES II, LLC' Address: -501 N. AIA .
Building Official .
City: JUPITER, FL., 33477
By: BILL GORDON
Date: MAY 23, 2002
POST IN A CONSPICUOUS PLACE