0403-372 (SFD)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
fx F F i i i� 311/05
-f
Date & ,� Signature of Contractor f _<( - i --
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.
StATE,,FtlPP 46.03. 333
(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 forth ith comply wit those m'V1: �ons.('!A� 4
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 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 160 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 mentioled pr' perty for in purposes.
nature - (Owned/Agent) =! + - • T r�"d Date •��/ � -
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 1!`_u9�}. q';r TRACT
JOB SITE
APN
ADDRESS
-OWNER
CONTRACTOR /DESIGNER / EN (NEER
MIR AV f-Tr.6 205
:�•rr. C=Zw�'���:�n�to�7;� [�:'��', ;3<!'Y? 205
r5����I�.7y, yy
,[q.d.d.�l.cru DS' �nii :�6:D •7 :!
TT5 '�33
SilvlY.♦;..AR D'i c!A J:L3fJ
USE OF PERMIT
Di'IVTOIX Fr' MIl..Y Dolor
f ffL.-) T 14 ALAN 1,A. PERMIT DOFL :INICI P INCLUDIE l5WC1C WALL,
11(X0! . SPA Oft ,DRAtWAY APPROACH, REDUCTION 0 PL A14 (11-TeK
IEE FOR MULITPLE ISSUA14CE OF SAME PLAN TYPL.
CUSTOM f)ir
NOFts'I:irPA.TIO 491,30 S30
�+ARxtURjCARPC3TLT 664.00 9F
G(` NSTP LtCTRYN FBE l M -000.418-000 fij,95610(1
PL&N CFTi;;CK iFEK 101-000-4311- 18 U?1L 1'9
MECi,MICAL, FE1? l n1 -(Y.10-4 21-000 S 10.0t.
ELECTRICAL FRE 101-i 00.420-W* $185.0:,
PLt ME111NO Fi?E 101, SIM 10
TRONO MOTION, FEE - RE.S1D 101-000-2.9)-000 $21.81
ORAK)IF O F? r 101,.000423.000 $150
DEVELOPER E f l'iNR IMP.JXT FL12 $2,405.00
ART IN i"ODUO PLAM, - RUIE 270-1)00-445.000 P151 1
SUB-TKYTAL
✓i fly~ ] � .E i-t��;'Ii� 'E 1?„
$A*293.34
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APiQ 0 5 rl i T(%TAj, F'Et6f't .I� EES bvJE NOWNO
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�'F�7�1d .* F i re.it,Wr-A
RECEIPT
DATE
BYEFI
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, .4
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NSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set BacksUnderground
Ducts
Forms & Footings
Ducts
Slab Grade Q14' Q
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
0. K. to Wrap //
F.A.U.
Framing
Compressor
Insulation / Z
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
FOOLS a SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground PI . Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping S ZZ7161VPlumbing
Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection y
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Vottage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
Certificate of Occupancy
ui�icv
_ot
-F 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: 81-830 COUPLES COURT
Use classification;. SINGLE FAMILY DWELLING Building Permit No.: 0403-372
Occupancy Group: R3 Type of Construction: VN Land Use Zone: RL
Owner of Building: BIRDIE_.HOMES 11.1, LLC. Address: 5 E. CITRUS. AVE. STE.105
.City, ST, ZIP: REDLANDS, CA 92373
By: GARY HARTMAN
�~ Date: August 19.2005
Building Official
POST IN A CONSPICUOUS PLACE