0309-106 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
L H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
C1I W Professionals Code, and my License is in full force and effect.
O =) ch License # Lic. Class Exp. Date
r` 7S's3Z4liC:
oZ r- .,,bate � � Signature of Contractor-
0.
ontractor 0
J U C:) OWNER -BUILDER DECLARATION
HW I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) License Law for the following reason:
Z_ ( ) 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).
co s`() I am exempt under Section B&P.C. for this reason
N Date Signature of Owner
ON
WORKER'S COMPENSATION DECLARATION
EL
crI hereby affirm under penalty of perjury one of the following declarations:
n ~ 0 ( ) I have and will maintain a certificate of consent to self -insure for workers'
W �= compensation, as provided for by Section 3700 of the Labor Code, for -the
D - Q performance of the work for which this permit is issued.
n Q L) ( ) I have and will maintain workers' compensation insurance, as required by
D U Q SAion 3700 of the Labor Code, for the performance of the work for which this
L' 0'H permit is issued. My workers' compensation insurance carrier & policy no. are:
It Z Carriere.. Policy No. ^
cb n 'OTATE FLUN'k� fSY�.•S7.0 ,
r,p
J(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
C •'8e, I .shall forthwith comply with,'t�hose_p'rovvisiof sem.
ate: wta+1 Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
.shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
. of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose equest and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and :'void if
-work is not commenced within 180 days from date of issuance -of such
permit, or cessation of work for 180 days will subject permit to cancellati
I certify that I have read this application and state that the above information '
• correct. I agree to comply with all City, and State laws relating to the buildin
construction, and hereby authorize representatives of this City to enter upo
the above-mentioned propertyfpr inspection purposes.
. [;�e9
Signature (Owner/Agent) ! C. �1=�DC�(� Date I
7.
BUILDING PERMIT'PERMIT# -
o3m-106
DATE VALUATION LOT TRACT
L /o s1tlR$�blS.iK) 29
JOdJ§ITE
APN
ADDRESS 78-72 D(3WLE—BRUSH. DRIVE
617-331-029
OWNER
CONTRACTOR / DESIGNER / ENGINEER
DEV.
PACIFIC HOMES
P.O. BOX, 10.23
77564 A r�;+imm aum m.IVE, Wme 113
LAQ'(3''INTA CA 92253
PA11ADE•.S'M CA X211
k?6Q)408.3495 CBL# 2953
USE OF PERMIT
'i.'1I13OLE.Ml+if_.EI.X MMI-MC.3
18;3 SY, SIM PUMIT i 30AS),40T I.N(;Y:.3JL?la BLOCK WA11A PiLCJiJSPa�
OR. O.RIVIEWAY A.7PPRO.A0I
f P.ACn C01104riTYf.i CTION I.monu
&'O:R':"ATIO 13.00 SP
Rm?�14;.m5A'1i'iF'k� C'06r oir comrR TG:"B' opi
1.D s8'a
PRR���dj,:SZ'yyFj%Xi
(� gypypp_pq y�{�yy
C4.�8tl? l MICTION E'.L E 1'01-0 04/-41 8-000 •D� �/8117�
FEE
FLAX CHECK 1MI". 1(i'I-(kP1�Jr-439.31a�` r53G,00
lYt'6;EtSp�1¢}aEgk�'EO7I:�#11'e 101 -(f1j( 0-43913 3111 8 4250.00
FJ tip f
M L• skl.7,c9.d!1ICAJr FEE � ,S iA'! "i/�.fii•'�41 ^W3lW .. QfJ Y,oV
FEE
'
%lact'mdu.1 n l.4YB='moi*4�rOTCt�1� x,11.9
PLU)MBIt:Et: FEE 101-000419-000 $04.00
$'T1TONO MOTION FES": RUID 101-000-241-000
011.A;IHN-0 VEX 101-000-423-000 � rt 3.520
DEVE110118, IMPACT, °. $2,405.00
i�Pt�,fv)S�.ri.Jlii 1ti1-tl0�-�1,�3.-3�i;3 `�ltsrs.00
.
tSWB7T,caw'I.ALrpt`3MMUC"TIONAA7IpPr��1+tt'$y1�C:�'1�ya1,T�jC�iTEjOyi}�^`
$4,(f`fr)6q'I�Ss:'s
�1 n
(Y{1
TOTAL PYM1;€'.I' .F3a19.'S DITE X",
3 � ��03 • � .
ISE?
c C`N ANCEA�
BY
m
DATE FINALED ' `
INSPECT
INSPECTION 'RECORD
OPERATION
DATE
I INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
. MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms& Footings
Ducts
Slab Grade
Return Air
Steel ,?�J E3
Combustion Air
Roof Deck Q - _
Exhaust Fans
OX to Wrap
F.A.U.
Framing
Compressor
Insulation p - /f.-
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 _ S
BLOCKWALL APPROVALS
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 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
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring _ 5
Low Voltage Wiring
Fixtures
Main Service
Sub Panels 41
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final 3 - -
Utility Notice (Perm)
COMMENTS:
- Certificate of Occupancy
V ,� • II''II y
OF'T9� Building & Safety Department
a
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: 78-720 BOTTLEBRUSH DR.
Use classification: S.F.D. Building Permit No.: 0309-106
Occupancy Group: R63 Type of Construction: N V Land Use Zone: R L
Owner of Building: PACIFIC HOMES Address: 77-564 A COUNTRY CLUB DRIVE
STE 113
City, ST, ZIP: PALM DESERT CA 92211
By: G. SHOWALTER
Date: 03/26/04
POST IN A CONSPICUOUS PLACE