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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
DateI v.1
4 � '' ' Signature of Contractor
14 1
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 6onsent 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 NATIONAL JTf' OII4 F': Policy No. ' W+ IXI)
(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 sl all forthwith comply'with'tl ose proyrslons.
Date:' '.....+ ;k t4_s .:r 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 propertyfor,inspectiompurposes. +
Signature (Owner/Agent),�' Dat
PERMIT #
BUILDING -PERMIT
DATE VALUATION LOT TRACT 30023
JOB SITE— ry
ADDRESS .Y._' jF. •�•SelrL?N,F :4 LAN /
APN Mot -270-017
OWNER
CONTRACTOR / DESIGNER / EN (NEER
60.311 31MOUY PARKINS 14Y
81.26.0 AIM NtJE 62
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TMERMAL :,A 92(t83
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USE OF PERMIT
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CITE' 0l- LA a tC!:s'I A
FIIMlANcC !.-.; r.
,
RECEIPT
DATE
BYT
FIN ED
INSPE R
—
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap a3
F.A.U.
Framing
Compressor
Insulation
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 Af2P5OVALS
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)
4D
Mainiero, Smith and Associates, Inc.
Planning / Civil Engineering / Land Surve. •ing
777 East Tahquitz Canyon Way. Suite 301 / Palm Springs. California 92262-6784
Telephone (760) 320-9811 / FAX (760) 323-7893 • e-mail info@mainierosmith.com • www.mainierosmith.com
May 7, 2003
Department of Building and Safety
CITY OF LA QUINTA
78-495 Calle Tampico .
La Quinta, CA 92253
Re: Form Certification
Tract No. 30023-2
Construction Sequence 1-F
Gentlemen:
This letter is to verify that the following building forms have been checked for elevation and
horizontal location by Mainiero, Smith and Associates, Inc. and found to be in substantial
conformance with the approved Precise Grading Plans. Finished floor elevations for lots 127 -
135 and lots 167 - 171 are as follows:
Very4JVa
s,
StevL.S. 6500
SJV:tt
cc: Hector Guzman, Engineering Department
Mike Groessl, Shea Homes
1.AN D
$TEVENJ.VAN FO
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REG.EXP 6A La
fTgl� OF .55� *Q
Pad Elevations
Lot #
Address
Plan
Field
Difference
127
81759 Brittlebush Ln
426.90
426.87
-0.03
128
81771 Brittlebush Ln
426.20
426.18
-0.02
129
81783 Brittlebush Ln
425.40
425.39
-0.01
130 1
81795 Brittlebush Ln
424.70
424.70
+0.00-
131-
81807 Brittlebush Ln
424.10
424.12
+0.02
132
81819 Brittlebush Ln
423.40
423.41
+0.01
133
81831 Brittlebush Ln
422.60
422.61
+0.01
134
60356 Sweetshade Ln
423.20
423.20
+0.00-
135
60334 Sweetshade Ln
1423.70
423.72
1 +0.02
167
60380 Chelsea Ct
428.50
428.53
+0.03
168
60402 Chelsea Ct
428.10
428.12
+0.02
169
60424 Chelsea Ct
427.30
427.29
-0.01
170
60351 Sweetshade Ln
423.50
423.51
+0.01
171
60329 Sweetshade Ln
424.10
424.18
+0.08
Very4JVa
s,
StevL.S. 6500
SJV:tt
cc: Hector Guzman, Engineering Department
Mike Groessl, Shea Homes
1.AN D
$TEVENJ.VAN FO
v
REG.EXP 6A La
fTgl� OF .55� *Q