9901-122 (SFD)LICENSED CONTRACTOR DECLARATION
`I 4eby 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
iSalt9' B %z3t30
Date -�
Signature of Contractor
OWNER -BUILDER DECLARATION.
I hereby•affirm "under penalty of perjury tfiat I'am exempt from the Contractor's
License Law for the following reason:
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).
as- 'owner�of'the`property, am- exclusively. contractinb with licensed
contactors to construct'. the, project ,(Sec. 7044, Business' & Professionals '
Codef
(.) t am_exempt under Secfion B&P.C. for this reason
Date Signature •of Owner
WORKERitOMPENSATION 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 3,700 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:
_ Policy No.
(This section need not 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 (should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Cod(, I shall forthwit(t comply with thos�o�visions.
a
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
ofJhe Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
fo6'a mpermit subject -to, the conditions and restrictions set ' forth on his
application;:•-
,:,• ach.person; upon whose behalf this application is made & each person at
who'se'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
' &.h, old harmless the City of La. Quinta, its officers, agents and employees.
ny: 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 l 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
thbe a' bove=mentioned property for inspection purposes.
SI' ature' (Owner/Agent) _ � ... _... Date !
BUILDING PERMIT PERMGT#��9
DATE VALUATION ,�t�21 Otb .�0 LOT 7 TRACTJOB
SITE
ADDRESS �!-.� 9-76►�i i,�si43r ��N
y
APN 769-80-029
OWNER.
==
CONTRACTOR / DESIGNER / ENGINEER
SOMI -FERN HILLS, LLC
R.C. HOB.BS Ciba SOUTHERN HILLS, LLC
i 4_V E 04AP&CAN A%rE., Ste :[00
53-960 PGA BLVD
ORANGE CA 92886
LA QUINTA CA 92253
(714)633-7260 CBL# 5487
USE OF PERMIT
SiNOU PAMfLY OWEL.LING
LOT 7 -PLAN 3AR - 114)- FORMT DOES NOT NCL7L11).ir BLOCK WALLS OR
POOLS. PIAN CHECK M,,REIXJCED 75% FOR MULTIPLE ISSUANCE OF'
SAME PLAN TYPE.
CC3S'1'0A4 C(.:) iST,PUCTJ'0,,i4 3,3r4-00 SF
PORC.H/P.A.TIO 318.00 SF
GARAGEICARl"C7R'I' 700.00 SF
ST A, 1✓:� COST O CtI!'dS'.i KUC ION
28%62q.'20
PERMIT FEE SI31VIALARY
CONv!'f UC`I'IOIgF; S 1.01-000-41.8-000 $1,273.00
PLAN CHECK. Fa 101-000-439.318 $260.00
MECFIAN•1CAL F EX 101-000-421-000 $.124.00
r--.'�It1CAL liE1's 101.000-420-000 $18.032
PLUMB1140 fiFiE 10}-Qi10-=119-000 $205,75
S'i RO1` 0 d4TO ION 1rES - PXSID .101-000-241-000 241-000 28.06
GRAWNGM. 101.4100423-000 $20,CaCt
-I NFRAS'1`R1JC'I f M FM 225-000-443-342 $6.000.00
ART Ii\I.t?'t7i3I:IC P.LACE 3 - RES R: 10;1-000-255-000 $45.1.57
SUB41Ul'AL CONS'1't1.C.iC" 1 ON !V4D PLAN CHECK
ir8,55! ?0
LESS ,PR -FAD IfEES
4).tit3
TOTAL, PERM IT FEES NOW
$8;651.90
RECEIPT
DATE -�/
81 -,�
DATE FINALED
INSPECTOR
:,% Jam' ,, �, w , � � 1.:.•
E
INSPECTION RECORD
41 OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings 1A
Ducts
Slab Grade
Return Air
Steel 1.Combustion
Air
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Compressor.
Insulation /
Vents
Fireplace.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROV LS
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
Pool Cover
Sewer Connection MM
Encapsulation
Gas Piping
Gas Test
Appliances
D
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:
-...mow �.rw. � �rT'..++w : %rrtr4-•,�,�a� m.'!.".. • ,r .-.. � _ .... � .. _ y.., _ - ;r _ '" � _ _ ..
CdAernncate'p enc
a
t ofla wuinta
. 04 i and Safety Department CFM OF
This Certificate issued pursuant to 1rhe 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: 54-526 SOUTHERN HILLS
Use Classification: SINGLE FAMILY DWELLING Bldg. Permit No.: 9901-122
Occupancy Group:- R-3 Type of Construction: VN Land: Use Zone: RL
f
Owner of Building: SOUTHERN. HILLS; LLC Address:
J
Building Official
City:
1430E CHAPMAN AVE, STE 100
LA QUINTA, CA., 92253
By: DANIEL P. CRAWFORD JR.
Date: 4/7/2000
POST IN A CONSPICUOUS PLACE