0202-252 (SFD)i , 3 a. .,
."t. LICENSED CONTRACTOR DECLARATION
-ii 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 #. ' tic. Class Exp. Date
191561 13 3M 1102
Date 4&)-ZpSignature of Contractor
- OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury thatI 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.
I OT ATE FU14D 1661391 IM
(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 provlslons,of Stion,3700 of the Labor
1 r. / .
Code, I sh 111 forthwith comply with those ,provisi' ns.
Date: ! G /i ) ADDlicant ?? �f'111,x" i
,Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation,, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a , permit subject to the conditions and restrictions set forth on his
application..
1. Each person upon whose behalf this application,is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
(.certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon,
the above-mentioned property for inspection purpfos`es:
Signature (Owner/Agent)
{BUILDING PERMIT = _ PERMIT#-
t
DATE VALUATION LOT 0W, TRACT
�� :-� �1����36� 1 �� 261 �2•
JOB SITE" "
ADDRESS
AN
P
VIA A
�#'� £? t�'l(T� 1�Si
OWNER
CONTRACTOR / DESIGNER / EN INEER
C'MMAY d't dC"iRa1PAsNY
CsMA:i AY & COW. ,
174_ R 1'R'.E - ST. 0) 06
17,480 B� 1 TT1;1 Sr 0106
..
C11 4)5M 44 •0 CM9 4485
.
USE OF PERMIT
OU,:l A10;T xlWT!l(:I.11 JG
St?O - LOT1,38 3?FAI,! WAR 1• UMT .DOES NOT INCLU.D9 BLOC
WALLS, P004 SPA OR D'EWAYAP$`ROACH
! UC 'vOMM'4A`V 1,ION 2,,42100 9T
PORCHMATIO MOO S Y,
CARAeC. EM' RPORT 410,00 F
'R-7 1r£tMnW CONT OF CONFIRU'G.71700
145,1.46.40
&"•'ONSTR>f,DG1`ION FBE 101.000.4,18.000 08@01 4
PLAN, CHECK fIUZ 1131-000-439.318 $643.93
WE DEPOSIT 108T000 -439w1318 VS0100
MWHA;NICAL FEE 1£21.000-:11.21-000 $08.50
MM-Tit1CA1. PER 101.000.420.000 $142-05
lad.I3MBINGFEE $225.75
S°Cl3CS1+i'e1 tilt; TIOW FU -:k'.1�W 101-0,W441-000 $14:31
GRA1:'9MPELF $20.00
s5EV1':i.:afPER IMPACT FEE gl�9W`i:�r
8_11 ` L C:U 1'RMtn. l ?t � fc31211JAN' �'�'��:"M
ISM PRF-FAW MRS
�3 'i .
-$250V!
r ag MAR 2 9 2002 ° 11110aff11 INS DUlt NOWOFLAQ
WA
x •�?�"��' SP1''. ,
RECEIPT 4
DATE BY :
DATE FIN LEED
INSPECTOR
4.
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
—Z
Ducts
Slab Grade
— —
Return Air
Steel 4. fz
Al —2 — 2
Combustion Air
Roof Deck
— ,Z
Exhaust Fans
O.K. to Wrap
y 2-02
F.A.U.
Framing
Compressor
Insulation
_-1/5-02—
—/ —6 7
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wali Firewall
Exterior Lath
Drywall - Int. Lath
I
Final
Final
POOLS - SPAS
BLOCKWALL
APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste LinesZ.51
Heater Final
Water Piping
Plumbing Top OutEquipment
_/�_—Plumbing
Final
Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
57
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
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'Quinta,
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: 47-040 VIA ANTIBES
Use Classification:
SINGLE FAMILY DWELLING
Bldg. Permit No.:
0202-252
Occupancy Group:
R-3 Type of Construction:
VN Land Use Zone:
RL
Owner of Building: CANADAY AND COMPANY Address: 17480 EAST 17TH ST #106
Building Official
City: TUSTIN, CA 92780
By: STEVE TRAXEL
Date: 02-07-03
POST INA CONSPICUOUS PLACE