0202-254 (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
$(;1.561, B
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:
( ) 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.
STATE FUND Jobj39i-01
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) I certify thatin 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: 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.
h
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.' j
& hold harmless the City of La Quinta, its officers, agents and employ el
J;
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
PERMIT #
_ = BUILDING PERMIT = -- =- -
DATE)) VALUATION LOT �()!r�. TRACT
!� yy ,,yy�am ,��t/�l 77 �i7 t� rt et
152
JOB SITE
APN
ADDRESS
47 -OM VM "MUS
4,60 014
OWNER
CONTRACTORS/DESSIG`NERy/EN INEpE�Ry
G.%�kD1�dfim,,A & �y`�i'v31'>.Mf.V 8
gp
�v.C'Aa.'�7.t'sL1d'AY9 ,k, 4ii., 1,61C;e�LC'C'3.
170()F. 17T4 -SIT X31W
1"]4 WE, )TIM 7L 0101
TUSTU4 CA 92780
UST. CA, 192,190
Ci 14)508.44 d0 t<Kt•Si 4485
USE OF PERMIT
3WOU FAM,' DWR LWG
SFA > LOTt40 PLA14 IQA. PERMIT DORS NOT 04C>f. UMP, iiST.,OCK
,UDUCTION, 13UE `CO 'RQULTIO t 1SSUANCZ OF SAME 111�AN 'T'A'M
TRACT 001113TR.4iCTIOiV 2,42,4.40"m
PORC,HtPATIO 3W. Go Sl%
0ARAt7PWARPORT
hVnWA 'XD COST Or, C:Q.N91KU'Cr'. 024
145,146.40
}?KRMrr r,XR SUMMARY
CONSTRUCTION FF'X 101-000.418.000
PLAM CHRICK FEE 101-000439-318 $165.99
MECHANICAL AL FEE 101.000.421-000 $98.30
LP.LECTRICA1, FOR, 101-000-420-0130 $142.05
1'1.i1z BWOFEY, 101-000.4119.000 $125173
STROM0 HOTJON FPZ - MM13 -101-000-241.000 $14-1
ORA.D1NG FM 1.01.000- 4233-000 $20.00
DEV FA, OP ?1.1 IMPACT ;ZE i,aa7. G0
' •., ... iAfjyy^M T, 4.•OFV87bc<9MO. AND PIAN C5'al`.CK
T*,27 4..29
, a .4.rL'w➢ir A'T.�.GY'.6"09000 b4w
$0,00
-
2 2002 01 rCYnLrrmwFm �?L�7'� 1ipw
S3,2 I4��S�
MAR
r
�� ®frit AQUIMTA
RECEIPT
DATE
BY ••
DATEE�FINALE��{
INSPECTOR
A
INSPECTION RECORD
OPERATION DATE INSPECTOR
BUILDING APPROVALS
Set Backs - -I,-
Forms
Forms & Footings At _z6-2_,
Slab Grade </— Z
Steel 4 2_ - v
Roof DeckIL - L
O.K. to Wrap - p2
Framino
ace T.O.
Wall Insulation
Wall Firewall
or Lath
ill - Int. Lath
_'ZY-
OPERATION I DATE I INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans & Controls
Final _ 0 7i 7
BLOCKWALL AP ROVALS
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
y _ _ .z
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
y- / _ Z
Encapsulation
Gas Piping
Gas Test
A. 1 ,
I Final
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wim
Fixtures
Main Service
Sub Panels
Exterior Recepta<
G.F.I.
Smoke Detectors
Temp. Use of Po'
Notice
COMMENTS:
f
fiffoate of Occupancy
Citv of La. Quin ta
'Building and Safety Department oF-
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: 47-005 VIA ANTIBES
.Use Classification: SINGLE FAMILY DWELLING Bldg. Permit No.: 0202-254
Occupancy Group: R-3 Type of Construction: VN Land Use Zone: RL
Owner of Building: CANADAY & COMPANY Address: 17-480 E. 17" ST #106
City: TUSTIN, CA 92780
By: STEVE TRAXEL
Date: 10-28-2002
L.Au11u91 ly V I 1 I%, U
I POST IN A CONSPICUOUS PLACE