0304-201 (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 =) M License # Lic. Class Exp. Date
I-- CY U) 1768595 B C11 DIC 14,130103
UJI
~o Z r , r Date �• ~ -� ^� Signature of Contractor,`-
O r- I.
�p OWNER -BUILDER DECLARATION
J
W W r- 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).
C0() I am exempt under Section B&P.C. for this reason
LO
N Date Signature of Owner
p CV
0)
d< WORKER'S COMPENSATION DECLARATION
C:, Z I hereby affirm under penalty of perjury one of the following declarations:
F2p () 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
Om � Q performance of the work for which this permit is issued.
< O (. )� 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
11 0)H permit is issued. My workers' compensation insurance carrier & policy no. are:
It z Carrier 131,7 ,TS FliRID Policy No. 10,',16164 ?e'
ob d
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: _.� „�: Applicant
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
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
ZY
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 L,
BUILDINGq PERMIT PERM' W 2,01
DATE VALUATION LOT ir1 TRACT
-•j
JOB SITE 77-•290 CAMI ! O QVINS S1r NA
APN
ADDRESS
OWNER
CONTRACTOR/DESIGNER/EN (NEER
90K" s~C:URTY ARD HOMIS
WI; DEEM, 114C & 1 D NEXr w INS .4•`V° f.
.
7A01. 51-11PY1�'•':+1y:;GDh'Vi�.7R�.T
Z;
A +
�4,575:T�AlgDATvL%
TA yy A 92V'
'
USE OF PERMIT
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-sa
�e ('IJ - IX 1, KL3 _ i. 7 VII iaai L MY.PhJ !Y•./C �!'.'1.r 5+.1 r.V`./tilt .
P0014 FIPA ORitOi�.i4 II10N TO F's'AN C`•.i'iJE.C`K
F)!.F D1.31t TO I'AU1,T1Pt.E IS13i%et1.T'X2 OF SAIAZ v'i.A'11 "i'YPE
1'
GAULAORAIARFORT 3F
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COMM'WC'1ION RE 1'314,00.41 13.000 1171Kt tip,
P? A'H C11i cK. FZr_0 101-000-439-311:5 W,3,.17
MECRAMW.14+11F Fr 101-W01-42Iv000 SWI ,;�G
Fel" iIC RAC.A1. be.It 21.00(1 4210-000�W,my's
I3LZ'1M1)11al411rLE 1 U1:.at3U,.4.19!,0 JCI 11.51£.It) 0
5 -
'ITRO140 AfOTION FRY, .1dFZiD 1s±) -01)0.24 j -000
01 -000,42Z-000 $i.
ME-'iCAAl. 0.)?!1'8TSfC1'1t:?9 WD Z��.�t`M CT -I ,(OX
MAY 01'20 3
CITY OF LA QUINTA
FINANCE DEPT.
RECEIPT
DATE'
BY , t
DATE FIVALED,
INSPECTOR
INSPECTION RECORD
OPERATION j
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
OX to Wrap
O
F.A.U.
Framing
— p
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Tib/
Drywall - Int. Lath
lj
Final
Final l
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
I I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
— d
Encapsulation
Gas Piping
Gas Test
Appliances
✓
Final
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) - AW1
COMMENTS:
Certificate of Occupancy
OF'>119� Building & 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: 77-290 CAMINO QUINTANA
Use classification: SINGLE FAMILY DWELLLING Building Permit No.: 0304-201
Occupancy Group: R-3 Type of Construction: V-N Land Use Zone: RL
Owner of Building: RGC COURTYARD HOMES Address: 301 SHIPYARD WAY
City, ST, ZIP: NEWPORT BEACH, CA 92625
_`ate By: KIRK KIRKLAND
Date: NOVEMBER 23, 2004
Building Official
POST IN A CONSPICUOUS PLACE