9909-227 (SFD)LICENSED CONTRACTOR DECLARATION
I h�eby affirm under penalty of perjury that I am licensed unciWprovisions 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 #. Lia Class` Exp. Date
jl L
IT
"Date Signature of Contractor` Jr
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).
( ) 1, as owner of the property, am"exclusively contracting 'with' licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
O I am exempt underSection 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.
GOLDEN EA IX INS.. NWC; -51406"1
(This section need riot be completed -if the permit valuation is for $100.00 or less).
( ) .1 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
r - gi � t •
Subject to the w6rkers' compensation proVislons (of Section 3700 of the Labor
Code, I shall,fo6with comply with those prov �Slons�
s APPlicantxt
Date: 7
/�
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 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 auihorizer..representatives. of this City to enter upon
the above-mentioned propetty for inspection'purposes. .
r
%/ignature (Owner/Ag rit)' � "Dat "O � f/
t
BUILDING- PERMIT PERMIT# ..
DATE���
' p• p� z � � VALUATION LOT
1 sno,x .6o ,.2 .
JOB SITE
ADDRESS-
-,55-"4 WAN
APN
7169-4_,_50-W I
OWNER
CONTRACTOR/DESIGNER/ENGINEER.
a
CENTURY 4, RO VELt. Q' ON1.t4�I�1Y'd1T.EES
CENTURY C,T.%� IELL "t~;CDlb9�MUNfl IES
15-15 SCD. ` D" SIRE 1, SE1. k"11.00
353: SO. "0" SI'R ET' S'1 . ,#200
SAIN BERNARDINO CA 92408
WJ BERNAll2. J1,10 CA" 92105
(909)381.6007 CIBLA 2.1.20
f• / '
USE OF PERMIT
, N Z' " 47 4 ' IPT ` WYZ
Si"1:; - Wf 2; PLAN 3R, - 3?!*.i8iVff DCOE'S :tiC e INCLIM BLOCK WALL
OR POOL.
CUSTOM CONS'1'RUCTION' 2.308,00 SF
.POR ,?Xr. rt,SF
GARA:GFIC'ARI)ORT 3fs5,Ot1 Sty
EST AXED CWS' OF i.''f�N.VfR'UCTION
PERMIT FEE SUMMARY
C ONSTR1JCr1ON r 101 -000 -418 -OW $993.40
PLAN CRECK F'E8 $826,43
INIECi'3AIq. CAI, "% . ... 10l 00421-M $98.50
MECTRIC AL lEtFE, 101-060.4204)00 $152.75
PLUXIBING 17M 101-00x•4.1.9-000 $174,50
STRI700 AIOI I014 - Ii,£,SID 101-Si3O-2411 OOD SV2O.02
UltAUNG FEF bxlrjo
1JEdELOP.F-11 INiI'A> N' FEE
ART 114 PUBLIC PLAC E.$ a RiS1r' 7Oi 253--o i mz%.0
tai ;y
SUB CONSTR.IJ'C'1`101q•AND .PLAN CHECK _
�r s" � "44.0
LESS PRE -PAID FEES
$i,N)
TCA'.1'AL PEMUT FEES DUE NOW. .
54a432.90
RECEIPT
DATE
By
DE IN ^
I PECTOR
ZnZ
V ; , .
A
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings !
Ducts
Slab Grade Q
Return Air
Steel
Combustion Air
_
Roof Deck _
O.K. to Wrap _
Framing v
Insulation
Fireplace P4.
Exhaust Fans
F.A.U.iC
Compressor
Vents
Grills
Fans & Controls
-_ _
Ile
Fireplace T.O.
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath (o
Drywall - Int. Lath 6
V _ _
Final
_
Final6��
POOLS -SPAS
BLOCKWALL APPROVALS
steel
Set Hacks
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
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
_d
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)
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10
Lam a'•� - ' _, y. -I
Certificate- of Dcmipanc -
,14
G�OF'TY�9ti F - 4- Buildin+ & Safety Department
a
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
x
.,,- provisions of rthe Building Code: and then various ordinances of the City regulating, building,, _
construction and/or use.
+
. BUILDING•ADDRESS: 55-444 TANGLEWOOD- t
K
Use classification: SINGLE FAMILY DWELLING `• Building Permit No.: 9909-227
.r
:
Occupancy-Group'. R-3 �� Type of Construction: FNI j Land Use Zone: RL
Owner of•Building: CENTURY CROWELL COMM -' Address: 1535 D STREET STE..200 •=
a City, ST, ZIP: SAN BERNARDINO CA, 92408
FF
' .
-_ , - ._ -_ - • By: BILL GORDON
.• - -.
-. - .':-- _ .. -_ .
Date:-DECEMBER 12 2002
'
Building OfficialIIH
r
POST IN A CONSPICUOUS PLACE -