0304-200 (SFD)LICENSED CONTRACTOR DECLARATION
U) I hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
04
W Professionals Code, and my License is in full force and effect.
O =) co License # Lic. Class Exp. Date
' W
C2) Z r- Date M, Signature of Contractor /�71 'A �+
F --BUILDER DECLARATION
C-) (D
W d 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).
C'')() I am exempt under Section
LO B&P.C. for this reason
N Date Signature of Owner
ON
QJ
z WORKER'S COMPENSATION DECLARATION
uo Q Z I hereby affirm under penalty of perjury one of the following declarations:
r H O () 1 have and will maintain a certificate of consent to self -insure for workers'
X w compensation, as provided for by Section 3700 of the Labor Code, for the
m_ Q performance of the work for which this permit is issued.
Q() :(5A) I have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
U-) H permit is issued. My ,workers' compensation insurance carrier & policy no. are:
? Z Carrier tiT A.'! X 3t UP Policy No. AV -3416.02
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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
3 subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date:' - i 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.
1
Signature (Owner/Agent) fit Date ,- t
BUILDING PERMIT PERMIT
DATE VALUATION !�'.'�>> r i .`.{ �% LOT 210 TRACT 8'•i j..
JOB SITE isTt��ii4t„���g�lAiY'`X
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APN�f
ADDRESS -
OWNER
CONTRACTOR / DESIGNER / ENGINEER
Rd,W,, LOURT YAPM RV MFPS
DOM DEW, ., `!] ' C r 9az 21I:;a'"� : �.' C:,!4:i'W.i. �_i&*V.
Ol �3iI�4'"f?R J �ii!s
467513 i�.ZW_5
NEW .F`C� e BVACH CA`,
I P� (;tL?Ill?T:+ A 0h
USE OF PERMIT
:014032Fa'iMI'& Y D9VU,:?.1: G
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SPA 01Z NR6VZ'3WWAY APj°'13ZFAC:4. 750/0 RrYDY.1 T101q 1111i (1111111WK
ME. DUE TO MU1.,11 PL -K 1S3'UA:'? X; i`.•1F' t3A15E Pf.,fl N TYPP
��*i.i"��f5t✓•l'�v,�.J;1�€'?�,� . �?'�.GO gaff`
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PLAN CHECKPEFE 101
MF.CHA4i1CFa.1. ".15 3C+3 •(t=r'0.42i-003 . +4t
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21Xr,TP.1C:,:a1.
1'''laCfM,l}lIG FUR 10 4X0-4 0-4 19.000
STY.i%Hi91+ OT30H 379E , RtS1 r".7 Ko 11.61.0•'2,1 -ill:'
C1.12.,fts= IX/11 File: f 0;
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SUS-IM"AM (71014�,MV l•E`Yl'7c;)K AND PLAW C'WCl'
69 1
MAY O 12063
CITY OF LA QUINTA ,
FINANCE DEPT..
RECEIPT
DATEBy
DATE FINALED
INSPEC OR
)•-r A
.' f fti.
/0 "Z �
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 (JL
F.A.U.
Framing
Compressor
Insulation - i "
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 APPROVALS
Gas
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top -Out
Equipment Enclosure
Shower Pans Z
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection Ai
Encapsulation
Gas Piping
Gas Test
Appliances
-
O
Final
1
COMMENTS:
Final
Utility Notiod (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)
r. Certificate of Occupancy
Wf
OFBuilding. & Safety Department
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:;77-300 CAMINO QUINTANA -
Use classification: SINGLE FAMILY DWELLING Building Permit No.: 0304-200
Occupancy Group: R3 Type of Construction: VN Land Use Zone: RL
Owner of Building: RGC COURTYARD HOMES Address301 SHIPYARD WAY
City, ST, ZI PLA QUI NTA, CA 92253
• By: KIRK KIRKLAND
Date: NOV 2, 2004
! dot 7r
Building Official
POST IN A CONSPICUOUS PLACE
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