0105-050 (SFD)' i f 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
7'.094 AT3��i��`��tiT,�pa' 03/31/2(
�,•.e..d.. �'X�
Signature of Cont -Facto �```• � L=•T"^ . -
! T OWNER -BUILDER DECLARATION
.I hereby affirm under penalty of perjury that I am exempt from the Contractor's
L' icense L'aw for the following reason:
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:
Cartier Policy No.
(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
Cone, I shall forthwith comply with thoseprovlsl ns.
ate:. {, f: s Applicagt
W,
.//Warning: Failure to secure Workers' Compensation cove40e 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 t
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building a e y
for a permit subject to the conditions and restrictions set forth is
application.
1. Each person upon whose behalf this application is made & each r t
whose request and for whose benefit work is performed under or pu nt t
any permit issued as a result of this applicaton agrees to, & shall, i mni
& hold harmless the City of La Quinta, its officers, agents and em loyee .
2. Any permit issued as a result of this application becomes nulla d void
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 can ellation.
I certify that I have read this application and state that the above information is
correct:`Tagree 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
BUILDING/ PERMIT--.. PERMIT#
DATE VALUATION LOT ��� -♦ So I TRACT
f 9 o7 _ _,, ._ '29960
JOB SITE.
APN
ADDRESS
OWNER
CONTRACTOR/ / EN INEER
22M"WA,RDIAd"Iff MCMWITZ 150
229QWA(W1fQW CLF, 6= 1.50
GwtiR014A C„/4 91720
C:tJi2,L9N•A CA 91720
�9b9)279.4f'10C1 � GfB'L.� ;5"13Si
USE OF PERMIT
`i
M., ou FA L y Dwn. C+
SFD v WT 7PLAN Q, - PTnMMaT DOES 40'r rNCLUD9 BLOCK
CUSTOM COWS 'RUCTIC)N 3042,00 BY
iF>{: RC HIPA'T IO 43kao ST:
Q&I2AORIC,ARPORT (SFp 1%494.80
ES21 t IED CCPV Or' CC3NSTRU OF
264,4&9243
FMMIT.� Iq.1MMAY
ca"riumow ni 101-000-418-000 $1,217,00
Pias
MEC9MANICAL FEE 101 -000 -421 -WO $92,00
ELtL.�"@',RtL" AL Tom, 10131-000-420-000 $176.a
PLUMBING nR 101.000.419-000 St 99175
irfRO NO M0V07.4 F - 'RL00 101-000-241-000 $26.4:3
(M-00ING FUR 101-000-423- OW $20.00
Aa f JRO�"# 0 225-00& 4*�-342 1,9n.00
T W K1.T1M l LACIN • RESIE 701 fi 00.25 5-000
U�
2001. col
>ri AY 1 0
CITY OF LA QUINTA 11 0TAL rmma rK1�1�3DUE No1T§►'
$4,78627
FINANCE DEPT
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
•Z"is�,
Y1,61
. OR :140IN
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS-
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings �ppvj�
Slab Grade
_ _
�p�/!�/l _��L_
Ducts
Return Air
Steel
Roof Deck
O.K. to Wrap
_
��Exhaust
�� (�
Combustion Air
Fans
F.A.U.
Framing(
Insulation
6414
Compressor
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior LathDrywall
3/4
- Int. Lath
/
Final '//
BLOCKWALL APPROVALS
Final
POOLS - SPAS
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 Test
Electric Final
Waste Lines
�/3/
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
_
/Q��/�
Pool Cover
Encapsulation
Gas Piping
Gas. Test
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
Final
Utility Notice (Perm)
Certificate of Occupancy
City of La Qdinta
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
80-916 SPANISH BAY
Bldg. Permit No.:. 01.05-050
. Occupancy Group:R-3 Type. of
.Construction: VN Land Use Zone: RL
Owner of Building: CENTEX HOMES
Building Official
Address:, 2280 WARDLOW CIRCLE, STE 1.50
City: CORONA, CA., 91720
By: BILL GORDON
Date:' 4/25/02
POST IN A CONSPICUOUS PLACE