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LICENSED CONTRACTOR DECLARATION
/:,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
20�t�:11 13 C36 0.4,21.11 1113W7 .
Datel dl 2 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.
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 STATE VUND Policy No. 15, 035
(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 proves ons.
,Date:. 1 21 F ;- Applicant � a`'•"""`
_ r
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 r
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•thi's City to enter upon,;
the above-mentioned property for inspection purposes.
S'i nature (Owner/A ent) �`' A Date••3 j ✓7`,'•;
BUILDING PERMIT PERMIT#
DATE VALUATION LOT ��3U&-191 TRACT
,1 p}�� {{
912
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JOB SITE :'
APN .,
ADDRESS :y iR►►�.�.�,�R��s�t�� ' F7
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OWNER
CONTRACTOR/ DESIGNER/ EN (NEER ..
J MS =," AP
JAI -4-F8 C. BUP 11 AP, .R,
P,.0. P,(YX 2.97
7 3 -:111 003 FI DDUOTT!,"._C� LPY. E
PALM DRMR'T CJS. 92261
PALM e� M"IRRI CA k,2,61
(;16107774*72 C,'S3:t:� 2905
USE OF PERMIT }
031~a`OLE filAlLx
160". 1S.Z .1,3PID TP�.':i<441 r DorsNOTIi4CLUDE i:iJ..00K INrA:L), P001. OR
N9M1.?'6 AYAPPROACH, 75% Rurlucrl 1''LAN CHECK FEE FOR MIJIr,`1'1PLr
PLANS fyUP.E Iii6;5USZ"
TRACT Z:OMSTRUC:TION 1,604,00 SY
PORC1.IPATIO 117.00 SG'
OARACR4VeATtPOR:1 446,00 8 F
.
UbA86! C✓FAO �6t7lRLLid
97,39.90
yFRW,T , SydWAR6
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CONSTRUCTION 10)-000-418-000 9 r5�1.;4Q
PLS CHECK F19'9 •101-000-Q-19-318 8131.24
r, &F. DEPOSIT 101-000-439-318. 42S0.00
NIRCRA.t3fMMe 1011-000-421-000 00.421,-000 00.00
1
ELWIRICAL FU 101-000-420-000 SIMM,
PL'UM13INO WE 1Cri -000-419.000 $124.00
S'i'[LONO M4'1IOR FEE REM 101-000-241-000 $934
t;Iid.AIDMIO i FIR 101-000-423-000 S15,00
PRECISE PLAN 101-000-441-345 $100.0
4 LESS F'R11-F-AID FUS
-$250.00
V311 W110
FEB 21 2003
CITY OF LA QUINTA
FINANCE DEPT.
RECEIPT
DATE t
BY J
1.#'•"'
D TE FINAUD
f��?
INSPE O
.. •, i . i:'in ,-., .l �y}- ,.i.. ..a,�.. F yr-('^'
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
_e 2 11
Underground Ducts
Forms & FootingsQ
if
Ducts
Slab Grade
/ OfReturn
Air
Steel
Combustion Air
Roof Deck
_
Exhaust Fans
O.K. to Wrap
/i
F.A.U.
Framing
_
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 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
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
Gas Test
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)Cl� KS'
Certificate of Occupancy
Cit of La Quinta �
Y
Building. and Safety Department .-OF.�°��
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: 52-420.AVENIDA. RAMIREZ.
Use Classification: SINGLE FAMILY DWELLING Bldg. Permit No.: 0301-185
Occupancy Group: R-3 Type of Construction: VN Land Use Zone: RC
Owner of .Building: JAMES. BELKNAP Address: P:O. BOX 297
City: PALM DESERT, CA 92261
By: KIRK KIRKLAND ' .
Date: JUNE 19, 2003
Building Official
POST IN A CONSPICUOUS PLACE