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LICENSED CONTRACTOR DECLARATION
f'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
87252 B OV29/120i
Date / 6 -0 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 Policy No.
ROYAL Al: W
(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 pr ul Ions.
Date: 040 Applicant—
Warning:
pplicant 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) `�;/�. Date✓
BUILDING PERMIT PERMIT#
9907-2.1.11
VALUATION LOT TRACT 4i,
DAN�06
811 993 0() 46 J F1
200
JOB SITE ADDRESS 47-905 Pil5U� All N�r1��i�,tl STREET
649-036-02i) (349-036-02i)
OWNER
CONTRACTOR/DESIGNER/ENGINEER
CA':LIS R1SIDE:�M, C7Aii'niF.s,
c tim.-L.m.us PLS]TD N1 -1:.L.0
5 i'A.t' X PLAZA, SUITE 40
5 CA1tK PLAZA, SUITE 400
IRVINE CA 92614
11ZV1NE CA 926I4
USE OF PERMIT
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PERMiTIFETSUNINIARV
C:O'NSrRlTc'f10NFf�X 101-000-48-01V $692.00
P1.A'ty t`it1iC7K VIIT, 1011-tif}0=439: t $1145 V
,
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dTCAT, s66.50
MIWC,I12XA1: i't~.0 101-000_420.000
PLUMBING H W 101-000-419-M $1,54.00
t
l.tE !0.1.001.1121.000 $20.0
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ART TO PUBLIC PLAT. li - RE, tel ; 701[-000.255-&X)
VulVt:1,UPFR.tNfIINCT$1,+
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$31158.9:3
RECEIPT
DATE
By< ��� D E FINALED
INSPECTOR
NC,
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
)
Ducts
Slab Grade
_
I
Return Air
Steel
1jj (N
Combustion Air
Roof Deck
! �_ ^1 00
Exhaust Fans
O.K. to WrapAvg:;�
�_ ��OSL
F.A.U.
Framing
V
Compressor
Insulation
g e�..+►�
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
2Z
_
I LA _.
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
Vemp. Use of Power
Final
Utility Notice (Perm)
Vim. �l� �Util 1V. �_ liVJr J�V V.i JUJU •�l.J 1 �, i.•J�. -�
N' 7/moi r1 T T T r T O -V T l T —v 7 1 T T T T V /`I
�l=I (JUUVIL) EIVUJIVEL1C11Vr (T
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E-MAIL TO SUPPOPMt GOU17SGROUP.COM SALES(iyGGUVISGROUP.CoAf
FP1%,110,,1 10 ')nm
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%rur CAaa alta\ Yael
Desert 1. ides DevviopffiCUL
78-600 Highway,i i l
Main Office
La Quinta, CA 92253
Re: Miraflores
Plan 3 - Lot 44
Plan 2 - Lot 45
Deaf NIL 1 ann1,;h4r1.
This tetter advises that we have observed the structural requirements that are -�isioie
during construction at the time of our site visit.
Gouvis Engineering believes that the as -built construction at the time of our visit is in
general conformance with our structural plans and relevant correspondence issued by
our office relating to the above referenced dwelling.
This report is understood to be an expression of profesSirynat oriniop by this.office, which
is based on our best knowledge, information and beliefs. As such it consists of a report
for only structural elements (as above outlined) and is neither a guarantee nor a warranty,
expressed or implied for other trades or requirements of subject dwelling.
n�ESICRespectfully Submi
GOUVIS ENGIN�;CC
President
Si:1r;. C'u-
Certif.'20510
No. 038276
Exp. 3-3I-0!
Ilk -f utas
Martie Vinoya
Project Engineer
r;OUKSEN.GI.NBEFIN.GGMP nu 1vrrHorrrrrcry.cc�:;soFcua.cc5s
4400 GAMPUSDR/1'E. SU?EA "' NLR'PORTBEfCH. CAUFORN/A S72/i{�(I • /0401 752-161 � • FAX(9401 711.5371 P
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FIELD. OFFICES • SINMEGO • PLE4S&MN INTERNATIONALOFFICE: Y/EMAXf