SFD (0101-071)LICENSED CONTRACTOR DECLARATION
I hereby affirrn 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 ' •
4'780 w A E ;sal E
� �
Date x;- Signature of Contractol
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, 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 1
() 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 wiil 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:
Cartier Policy No.
Ch tit- �kd M.aOLF ITWC!• $4.701401
(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, I shall forthwith comply with those provisions.
Date:,�Applicant
Y
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).- } ' �1 "' "' Date/
BUILDING PERMIT PERMT#
DATE VALUATION LOT TRACT
JOB SITE
APN
ADDRESS ;
40.E e`.i KATE VAJJ D
OWNER
CONTRACTOR / DESIGNER / EN INEER r.
140ro."CUTP".4x
501 IT, AM
55®4137 00't7MIl O HMIS
JUPIUM 1.7.1 33477
I'A QMuk CA 97,253
(760)564d5612 C V3 548
USE OF PERMIT
3n-) - LOT 47 PLAN 4=0 PEMIT DO' S 'NOT WC1,11DE 9Wt~K
WAL1.ROOiMA OR APPROACH 1-MV9WAfir',
CUSTOM (110 iffRUC:TWN 4,9 Z00 3F
PtI1+CT"ef:IATIO 1.,nl,fifl uta
C1�ti10'fl�titri Mi)
c" 7
n
N`kUM.P..M 6iY3 MAR
000-n18wE00
CONS a'iUCITAON FEE 1 01 -000-418-000
PLAN CHFIC9 me, 101-016-439-318 $1,3r/65
, C1
MMS'"`l-I.t°�'SWCL"..�i1�lb"S tn��t9�l'„r3?I.OtJ�Y $1;3�.SU�k�
1-'�! -rs
"TRIC.f4L.t/IMIP 1014000-420-000 $'476,53 :”
PLUMBIPHO FEE 101-000-4,19-000
sTRO7fi! MO`i'10N TFT? • fil�:� 1D 101 -000-241 -000
ORAD1,14101 101-000-423-000
}a??1a1r1.i�PT!r ]IMP9CT1KE $1,307.Ct6f
ART IN FUSLICKAMS- RF.�-ff 701 -000-2-55-000 S453.28
A.
Caz:AWAL C:OMM7.2'OT'i09 AND PLAN r— X
$5,881.36
1011AL PE s1'. t aYUF now
r-
RECEIPTDATE
/
BY / f
DATE FINALED
INSPECTOR
'_� (. , i
`i
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs_
Underground Ducts
Forms &Footings �f,
_ _
/L �,d f�(
Ducts
Slab Grade `�/ --
_
Z� ��
Return Air
Steel_
_ _
Combustion Air
Roof Deck
�` (�
Exhaust Fans
O.K. to Wrap
d
/L
F.A.U.
Framing
(0 G�
Compressor
Insulation�_
v L
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wail Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall Int.
a
3����X/
- 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 Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
��0�
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
A
��/�
Pool Cover
Encapsulation
Gas Piping
Gas Test
v/
Appliances Appliances
Final
COMMENTS:
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)
F.
I
Certificate of OccupancyT
Y
City o f L a,Q uin ta V
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 comp/lance with the various ordinances
of the City regulating building construction or use. For the following-,
BUILDING ADDRESS: 81-200 NATIONAL DRIVE
Use Classification: SINGLE FAMILY DWELLING Bldg. Permit No.: 0101-071
Occupancy Group: R-3 - Type of Construction: VN 'Land Use Zone: RL
Owner of Building: NORMAN ESTATES it LLC Address: 501 N. AIA V
City: JUPITER, FL., 33477 -
By: GARY HARTMAN
Date: 11/19/01
Building Official
POST IN A CONSPICUOUS PLACE -
" r.