9912-111 (CCOM)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
179699 B_ M/29/k4
Date � S g ature 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. _
COL -1,104 r. mss" rl w i," i. r_ 771)1
(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
worker 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 s all forthwo comply withth2� e ' rovisions.
ete: 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.
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 Bove -mentioned property f i pection purposes.
Signature (Owner/Agent) (r' 4L11< Date
BUILDING PERMIT
DATE VALUATION $6.*150,40 LOT
JOB SITE
ADDRESS �
OWNER
v'Otm.ILNT P1L3.,5, LLC.
1430 LI CHAI'ActAN AVF3, Ste 100
ORANGE CA 92996
USE OF PERMIT
3:t�+ s.i� . a�"�ivt'R1uN Af-c1aA 1�t�L .BL7.i.1ri.�i1
PERMIT #
1TI, tI-
APN
TRACT 28776
775-120-033
CONTRACTOR/DESIGNER/ENGINEER
1Z C""". k1Q'NS dba $0MEX1,11 HtL.LS, -LLC-
55-960 PGA BLV6
LA QUINT'A CA 92253
('714)633-7260 `::BIN 5487
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701-00-255-000
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'RrOT.&L1?ClrfMIT .F EaEN OVE NOW
RECEIPT DATE BY DATE FINALED INSPECTOR
6,359.40
$739,97
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings pv
Q
Ducts
Slab Grade
3 e0
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
0
F.A.U.
Framing
Compressor
Insulation
/
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall insulation
Condensate Lines
Party Wali Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final D
BLOCKWALL APPROVALS
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
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
1044 LPool
Cover
Sewer Connection
Encapsulation ,
Gas Piping
Gas Test
Appliances
Final
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)
COMMENTS:
_.
o
Certificate of Occupanc y a,..
City' of. LaQuinta -
__Auilding. 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: 54-592 SOUTHERN HILLS `
Use Classification: COMMON AREA POOL BUILDING Bldg. Permit -..No.: 9912-111 _
` Occupancy Group: _ B Type of Construction:' ., VN ^ Land Use Zone: RL
Owner of Building: SOUTHERN HILLS, LLC, Address: - 1430 E CHAPMAN AVE, STE 100
City: ORANGE, CA., 92886
,By: DANIEL P. CRAWFORD JR.
Date: 8/7/01•
Building Official
POST IN A CONSPICUOUS PLACE IF
J