9901-125 (SFD)UICENSED CONTRACTOR DECLARATION
L
I hereby affirm under penalty of perjury that I am licensed under provisions of
Phapter.9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full,foirce and effect.
License, # y Lic. Class' Exp. Date
-4*78690 V29AW
Vi,a,el, Signature of Contractor,��
OWNER -BUILDER DECLARATION
i hereby affirm 'under penalty of, perjury that I am, exempt from the Contractor's
Li6ense Law for the following reason:
l,'a.s'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
C6de).'
.1, aim, exempt under Section. B&P.C. for this reason
Date Signature of Owner.
WORKER'S COMPENSATION DECLARATION
1,: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'
comp'ensation,'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
ection'3:700 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.
WC 547;70.100
(This se , ction:need not be completed,if the permit valuation.is for $100.00 or less).
1'6ertify that in the performance of the work for which this permit is issued,
I Shall- not employ any person in any.manner so is 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 forth[tq comply with theseg�.
/P 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.
4,. tach 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 harniless the' City of La Quinta, its officers, agents and employees.
'i Any permit issued as a result of this application becomes null and voidif
-wo.rk_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. .1 agree to comply with all City, and State laws relating to the building
cqrjstructi6n, and. hereby authorize representatives of this City to. enter upon
the above-mentioned property for inspection purposes..
/Signature(Owner/Agent)� Date 10-
BUILDING PERMIT f- PERMIT #
DATE VALUATION .00 LOT TRACT 28905
JOB SITE APN
ADDRESS ig. swUT WEN ►HILLS)
OWNER CONTRACTOR/DESIGNER/ENGINEER
SOUTHERN. HILLS, LLC RZ HOBBS tuba SOMMN HILLS, LLC
1430 E C14APMAN AW1 , $te 100 55-960 PGA BLVD
OPLANGF. CA 92SR6 LA QUfNTA. CA 902-253
(7141)b33-7260 CBL# W
USE OF PERMIT
SO4GLE flAWLY WELLINNO
LOT t. PLAN IC -8FD'PF",. ff DOES NO`r INCLUDE BLOCK WALLS O.R
POOLS. PLAN CHECK FES REUXV) 750/oFORMU(NIPLE ISSVIAWTOF
SMa PLAN TYPE.
.1
CU31COA4 CONSTRUCrION 2,IM00 9E'
PORC"IXTIO 330.00 se
0ARAGWCARPORT 930.00 31~
EX13-Al 1,D Cil f Or CONSTRU010N
VERMIT FEE! SUMMARY
COWISTRLKI"r I ONF M!
101 -OW -418.400
PLAN. 0.113CKFEE
101-000-439-318
NiECHANICAL FEE
101-000-42.1-000
1105,00
161.WIIRICAI: FE -8,
161-000-4."x"00
$173.46
PL1JN1B1M FEE
101-000-419-000
$186.50
3TRONO MOTION FM - RESM
101-000-241-000
$23.92
GRADINOTS
10 1 -O(10A23-10W`
114FRASTRUCIVRE F
2254l00-443-34.2
.,ART IN PUBLIC R,ACFS - RES M 701-000-255-000 -
$347,93
841j".XIAL COMS"FRUCTM AND PLAN CHECK
LESS PRE-PAIWIFEES
239,479.00
$0.00
TOTAL PERMIT F E&N DUE NOW 1 $7,500.01.
IIECEIP,T DATE )
< r BY DATE IFINALED INSPECTOR
1 I
-7 - _""'
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O. K. to Wrap hy ffWo
F.A.U.
Framing L Of
Compressor
Insulation owe&&Vents
Fireplace .L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Dryyyall- Int. Lath
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 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
Gas Piping
Gas Test 10
Appliances
'
Final
COMMENTS:
/9�///vim
9�
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Law Voltage Wiring
Fixtures
Main Service '
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Ublity Notice (Perm)
OrtificateofOctupancy acs.
City of La-.Quinta..
Building and Safety Departme'n't -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
ollowing:BUILDING ADDRESS: -55-487 SOUTHERN HILLS
Use Classification: .SINGLE FAMILY DWELLING (MODEL, GARAGE Bldg. Permit No.: 9901-125
CONVERSION PEND/NG PERMIT NR 9904-152)
Occupancy Group: R-3 Type ,of1Construction: VN *Land Use Zone: RL
Owner of Building: SOUTHERN HILLS, LLC Address: '1430 E CHAPMAN.AVE, STE 100
r City:. ORANGE; CA., 92886
By: DANIEL P: CRAWFORD JR.
- 4 _ w
o'h� Date: 4/25/2000
Building Official
POST IN A CONSPICUOUS PLACE