0111-214 (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 Ex . Date
Date !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:
() 1 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 ine-urance carrier & policy no. are:
Carrier Policy No.
O'f'Alm FUND baf>"4tl�:iS
(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 theeworkers' compensation provisions of Section.37001of the Labor
Code, 1,, hallforthfw'' h comply with`•those provisions.
Date: /-- ,' � 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. t
1. Each person upon whose behalf this application is made,& each person.Bt
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 upo '.
the above-mentioned property for iinspectior�purposes!
Signature (Owner/Agent) t Date f '�
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
/ n; 41 29,457-2
JOB SITE
APN
ADDRESS
49 -Mi RANCHO FOII' E
10-M -
OWNER
CONTRACTOR / DESIGNER / EN (NEER
Fid DOX 11116
29-293 RANCHO 1A q?'t;n_WfA MIL
A qui 3Yt': C.EV, 92253
LA Ql wTA CA 92.25-1
.
[�A
i'60,7!1 -k9.4,1 1. 01 x9.76
USE OF PERMIT
:alrli . U)T 47 MAN M3R. i?'1:.:1M1'i' x;0MNOT INC: UM BLOCK WAUS, .
CUSTOM CONSTAIT M' a']W 4,243,00 -SF
PURC1`Ii'taATIO 522.00 Sir
f'�.�.R&C'6:T CIA1RPORT 710,00 OF
xsluvo Com-, m Ci3.,mucTio.t'e
:331,3NZAI
CONSTRUCTION PYR 10L -000-411E-000 S1,#U21,30
k',L N C,i-15Z.X FXF 101-000.439-318 9309,733
MEM"'ICA3 MSE 101-1000-421-000 S238,50
MkIC:"1'l'tIM, AMR, 101-WXI-420-000 5246.71
PLUM01'"o T RFI 101.000.419-M, $203.00
XfP,0140 MCYTlON FEF • ! ESM 10'1-000-241-i1 O $33,14
(Mt.SNNO, MY '101-0004U-000 Moo
9EV1E1O'.nPA YMPAC i` 1 +left .00
-ditT M PUBLIC RAM- WlC 210-000-445-000 M47
1
MU'CMON AND Mi• W' CREM.
LESS Z''-PAID.FE..2
` $4,759.05
$0.00
i-ff.C �.4.' VU E NO'S
)ms
� g U ��16
RECEIPT
DATE
BY
DATE FINALED
INSPECYOOR
�� hY
INSPECTION RECORD
' OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs !3
�= - Z
Underground Ducts
Forms & Footings 1
j - z
Ducts
_Z
Slab Grade ]•
=� r
Retum Air
Steel 1:
trl� 3 _
Combustion Air
Roof Deck f.
S - / - Z _
Exhaust Fans
O.K. to Wrap Ii
F.A.U.
Framing
Insulation ii
-z2 -Z
- ,?y -� _
Compressor
Vents
Fireplace P.L. j
Grills
Fireplace T.O. j;
Fans & Controls
Party Wall Insulation
_
Condensate Lines
Party Wall Firewall ;
Exterior Lath
Drywall - Int. Lath
1+
Final�
Final
�Q OZ
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs I
Electric Bond
Footings
S
Main Drain
Bond Beam
Z
Approval to Cover
'
?
Equipment Location
Underground Electric
Underground Plbg. Test
Final I:
Gas Piping
PLUMBING APPROVALS
Gas Test
_
Electric Final
Waste Lines
-
Heater Final
Water Piping
Plumbing Top Out J`
_
Plumbing Final
Equipment Enclosure
Shower Pans a,i.
O.K. for Finish Plaster
Sewer Lateral ;.
_
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances lb
Final
i;
COMMENTS:
I.
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole I'
Z= 3- c9Z
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service J.
Sub Panels 1'
1 , �/ —
Exterior Receptacles,;
G.F.I.
_
Smoke Detectors J+
Temp. Use of Power ),
IP
Final
Utility Notice (Perm) j,
s
Certificate of Occupancy-
City
of La Quinta
Building and Safety'Department
This Certificate issued pursuant to the requirements of Section 109 of the Uniform Building Code,
certifying that, at the time of issuance, this structure was in compliance with the various ordinances
of the City regulating building construction or use. For the following:
BUILDING ADDRESS:
Use Classification: SINGLE FAMILY DWELLING
Occupancy Group:
R-3
49-155 RANCHO POINTE
Type of Construction: V -N
Bldg. Permit No.: 0111-214
Land Use Zone: R/L
Owner of Building: TD.DESERT DEVELOPMENT Address: PO BOX 1716
Building Official
City: LA QUINTA CA. 92253
By: GARY SHOWALTER
Date: 08/20/02
POST IN A CONSPICUOUS PLACE