9909-248 (SFD)r LICENSED CONTRACTOR DECLARATION
I hereby affirm under penaltyof 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
141 14
,.
x
Date € {• � �?� � Signature of
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) .l, as owner of the property, or my employees with'wages'as their sole
compensation, will do -the work, and the structure isnot 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.
()e), 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.
GUM EAGLE WS, N WC 544468=01.
(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 provii�ons of S action 3700 of the Labor
Code, I shall forjhwith comply withfthose provisions :
Date: (P) �2 RI , Applic- .�• �.;ws s� .k'
V Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for, in Se.ction.3706
of the Labor Code, interest and attorney's fees. '
IMPORTANT Application is hereby made to the.Director:of Building and Safety
for a permit subject to the ,conditions and .restrictions set- forth on. his
application.
1: Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
.& hold harmless the. City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this, application becomes,null and void if
,work is not commenced within 180.days from date of issuance -of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and. State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property forliinspection purposes.
r
signature (Owner/Agent) -+ w —'Date
f fi.
PERMIT#
BUILDING PERMIT -
o
DATE VALUATION. LOT _.— -- TRACT
JOB SITEg `
APN
ADDRESS 5 - C% FIN W
� i
OWNER
CONTRACTOR / DESIGNER / ENGINEER
+.
C ;�i'ILT� Y l O'4 � .1 r,:aF°vi1 ,'l t `i ► .
CEMYRY CKOWELL CON A1:UNME
Is3.3so. 111yr krku-T, h"°'m-066
1335 `O. aDtl .SIRE 1d, R Jf200
SAN BERNARDINO CA 91N4M
SAN BERNARDINO CA 9408
i) r6r•.ti�r►7 CCI.# 2120
s
USE OF PERMIT
S(NGL VAMILY DWELLING.
SM - i.s3`.i' U PLAN 2A. - PEtRTvUT DORS NOT INCLIUM BLOCK W.h LL
ESL POOL PLI-U7 CMCK FEE RETATCE D 750/o FOR R i►>1L'(,'4' PLP 1SSUAW36 O
SAME PLAN TYPL
C.ilS'1'OM CONS'I'11'U('.1 SC. N 2112N.00 Sr
Pa7iEC''1 PA.TIO l tF.t3U w,
GARAGEICrA:RPORT 507,00 Sly i
+:,5d'➢.']MATED T (lip i".ONST(Y:�•i•�:"$'��Di�+t
.1. •,235.,>i D
YFMkXT fT- E SUAMA,RY
C'•C3Na'17liili",3 ONFEE 101-000-41-•000 $937.00
PL..'kN C1ECY. FkE 101.00(-439-318 $193,52
ELFC11MAL ('EE 1.08-0iD(}A10-000
^t'1
P1,iIMAING c 3 101-M-419-000 $03.2.5.
S`.iRr3q+iNG kv OT1f3'1v k'Et"•.'' ,.:MoSID !101. -ice -241-000 •'.
ior�€ian� z: ooQ
MAIDING FREkA
; -
DE"VO.rC)ER1W4C: FFE
ART 117 PUBLIC PLACES - R,NST7; 70.1 -WO -255.00-
SUB-TUXTA:L CGNS'MUCTCUN AND PLS C11rsC`r
4 ar?U3.i3G
LESS Pr F P.A1D'FEfiS.
$0.00
TOT'M..{ ERMIT FQ±a�%$3UF NOW.,
153,703.86
RECEIPT
DATE
.
ft;
DATE FINALED
INSPECTOR
,
i
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms &Footings
Slab Grade /
GIpA
Ty9
Ducts
Retum Air
Steel
Combustion Air
Roof Decks/
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
_
Insulation
Vents
Fireplace P.L1
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
_
Qa
Drywall - Int. Lath
_
Final
Final
BLOCKWALL APPROV LS
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
41 /_/_
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
(� 1—
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)
T C
' 'of Occupahcy�cate rte fCe
Cit
of La Quinta
and Safet Department , Maf
. Building Y7.
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: 55-066 TANGLEWOOD
Use Classification: SINGLE FAMILY DWELLING Bldg. Permit No.: 9909-248
Occupancy Group: R-3 Type of Construction: VN Land Use Zone: RL
Owner of Building: CENTURY CROWELL COMM Address: 1535 S. D ST. STE 200
City: SAN BERNARDINO
By: DANIEL P. CRAWFORD JR.
Date: 10/23/2000
Building Official
POST IN A CONSPICUOUS PLACE