0109-264 (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
Date,4' �'��+ Signature of Contractors r° /` r 'i f r ✓;�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 pf 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 W. LT.) ms- xhovc nos. Policy No. XWC-3441169-0.3
(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 forthwith comply with those provisions.
Date:r Applicant p.�'
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.
Signature (Owner/Agent) � ' % •� = Date`s
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 01W2M TRACT
3€1 24197-3
JOB SITE
ADDRESS 79-762 MITPENDE M WAY
APN
4 )7?,(i
OWNER
CONTRACTOR / DESIGNER / EN INEER
(211M1`'�,:�'ti°.iy�+(iy��wnp�.{.'�L,3gcoldi,�y�%7/��`rlM.
�:*,'�.1�ilU.R,�p`'yf�R.OU �:t��*Cp�Op
V.5:35 7. 0, i.1)-' "LITPAW. . k7d, - 0,20 !
�y�t�?y��3ai3
i 53J Noy .Y , p:-2�Z.\.-mr, �'IA.lf:n YV'290
Sx Mr'�sNAkS::)NO CA 92,408
SAN BENARTA`TO Cis. 92408
(909)3811-600 Q.O. 2120
USE OF PERMIT
SYD - :i OY 38, PLAN _5XA. PFAWIT .WENS -NOT INCLUDE BLOCK
WAUA lPOOI WA Oil DRIVEWAY APPROACH. TM PLAN CHECK IREE
RXD1 UC1*1014 POP !S8UX14CZa'rSAME PL&M TYPE
TRACT CONSTRUCTION 21021,00 3F
PORCHdPAt IO 11.6(13F
GARAW(LARPOR`1' 417,00 5F
1r.'MMA= COST OF C0MMOMON
21610W.80
JYMAW FIT. SUMMARY
CONSTRUCTION FRY, 101-000-41€ -000
tP'gd7�t;Vy�t,�HFIC(K PER 101-1`3;/A�9�•�' 391,31n8 �1ys�7,p1�?�
MECHANICAL AL d'ER 101-000-42 -000 960M
=X11TR1rAA.111p E 101-000-420-000 $197.58
P3:'6,ald#lctiNCi TIN 101.000.4 19-000 2148.00
U't'fr'cC8NU MOTION MP, . kWID 101-000-241-000 $11.81
OF2.AD1*90 :rid 1011-000-423-000 520100
DEVELOPER. DAPACT FM
YxC°a2t2"aleiiXX
,3 �..6
:ES4 �'1 —PAM FE9.3
Q
S0100
iJ :C WMEMAIT ''L?ODUBJ40W
$3,127'.W+
V
OCT p 5 2001
•
CITY OF � 4nQ11NTA
f3LPT•
plrlA�CC ` �.'
RECEIPT
DATE ,
By
DATE FINA413
.
INSPECTOR
kN
�•�5.o1J
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
Set Backs
APPROVALS
MECHANICAL APPROVALS
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Steel
G—
Return Air
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap e/ .S
Framing �, ?�Q y �fg SZ
Insulation J y
F.A.U.
Compressor
Vents
Fireplace P.L.
_ Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall -Int. Lath
0.J�1 67
"
_
Final/ S
BLOCKWALL APPROVALS
Final
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Waste Lines 16�Z Z/b� /��.
Water Piping
Gas Test
Electric Final
Heater Final
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection—
Pool Cover
Encapsulation
Gas Piping
Gas Test
, �, • (j ?j �� $7
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
Finalgyg�j
Utility Notice (Perm) � �Z�
/
o -z Certificate of Occupancy
4
Icaronnhn�
Ou
9w5
of 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: 79-762 INDEPENDENCE WAY
Use classification: SINGLE FAMILY DWELLING Building Permit No.: 0109-264
Occupancy Group: R-3 Type of Construction: VN Land Use Zone: RL
Owner of Building: CENTURY CROWELL COMM Address: 1535 D STREET STE. 200
City, ST, ZIP: SAN BERNARDINO CA, 92408
By: GARY SHOWALTER
Date: MAY 23, 2002
Building Official
POST IN A CONSPICUOUS PLACE