0210-311 (COMM)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
Orofessionals Code, and my License is in full force and effect.
License # , Lic. Class Exp. Date
,D•ate ,Signature of Contractor-/% f
p
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).
( ) 1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code). jw"
( ) I am exempt under Sect9on 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 STA:'t' FIJ�t?� Policy No. 046-00t 71.13
(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 -provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date:' r� J r Applicant `"'� % / !
f Warning Failure to secure Workers' Compensation coverage is unlaLul 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;.,inferest 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, i
& hold harmless the Cityi of La Quinta, its officers, agents and er ees.
2. Any permit issued as'a result of this application becomes null a
work is not commenced within 180 days from date of issuanCE Lich
permit, or cessation of'work for 180 days will subject permit to ca II ion.1
I certify that I have read this application and state that the above infoi nati n is
correct. I agree to comply with all City, and State laws relating to th bu
Construction, and hereby authorize representatives of this City to a er upon
the above-mentioned property'for. inspection purposes.
Signature (Owner/Agent) `� Date=!
BUILDING PERMIT
DATE T VALUATION LOT
JOB SITE y
ADDRESS Zoe alis6? n �MI.ifSiAJ,i6. dF.i��F.
OWNER
LA QTlII+I°.IA.
USE OF PERMIT.
C.C3W&T(fiJ-
PERMIT #
�ti€J-•fit 1
TRACT 29457.3
APN z1W Qi"
ZS"S'o'f^..,.vT'isrX .Al
CONTRACTOR / DESIGNER / ENGINEER
CA 92233 1,k Q1;3W1A, C.A. 92233
Q60)771-1941 CMIA4 2996
312 S.F. (RIARD .fiCJT3?y#.I.' &494 S.F. PATIO COlf''FR
COMM CONSTRUCTION 312.90 SF
PORCiiMATIO 4 94,00 Lit+'
EgnW7[ka) (110S"T OF C110NISTIRriallQu
-
30,742.10
PERKY V M hTUM 1ti:ARY
C(1A1S3'F{UCii(? FEE
'10)-000418.000
11391100
PLAII CT11WK mr,
b66.9z
FEE DEPOSIT
i�#9�aI�C3a43!i+��l>3
�s�tip,i?D
AQW"V,,"ICAL .FEE
t Ql-Qfltl�l�1 •f3Qdi
��9. �0
Melolf l.C•1L, T:PIi
101-000-420-M
tJ 4rA,�
Pk,ISMBINQ FE
101-0010419-000
1167.50
WikONO MOTION FEE, - COMM
100 -WO -241 -000
$0.40
ORA DING F.Et
101-000-423-000
X13.00
DIEVEL.0 PER, t%liF''AOIT k,L
,403.fl_�J
P111=1 : PL"Y
101-0901-"11-343
2ilki.0tl
ART IN F'UBL,ICr &'LrrlCMI - COM 10.000.443.000
2113171
SUB-TOTAX, COM. AND PLN14 C;i ECIZ :f, eaS.31
LESS PRE -PAM Fni'ti-.00MOO
P' 17 2903 �
1
i5EPT. w,f
RECEIPT DATEBY, DATF,FINALED INSPECTO
r, INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
W 'BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
p
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
/ —/ .— t
F.A.U.
Framing
_
Compressor
Insulation
Z — S
Vents -
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
-
Drywall - Int. Lath
/ -z G —
Final
Final -
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
z p
Heater Final
Water Piping��
Plumbing Top Out
/ Ji'`
Plumbing Final
Equipment Enclosure
Shower Pans
zOX
for Finish Plaster
Sewer Lateral
ZPool
Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Utility Notice (Gas) -C,"
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
X w.
•
L�
aha w .
MEMORANDUM
To: Greg Butler, Building & Safety Manager To PWD:
From: Steven D. Speer, Senior Engineer
Building Permit, Release
(this is an approval to issue a Building, Permit)
The Public Works Department has reviewed the following project:
Description: ,3 1a Q,�-
Address or general location: - �EFFi✓ R501`i-
APN and/or legal description: (9 QQ- a, t p
The Public Works Department finds that:
issuance of this Building Permit does not require Public Works
tx Department approval.
... issuance of this Building Permit is approved by the Public Works
Department.
Senior Engineer
0,3
Date
• l
•
Certificate,of Occupancy0
U � • I,I%��/�
IKca�oinm�� .
G OF9� Building & Safety Department
This Certificate is issued pursuant to the requirements of Section 109 of the California Building
Code, certifying that, at the time of issuance, this structure was in compliance with the
provisions of the Building Code and the various ordinances of .the City regulating building
construction and/or use.
BUILDING ADDRESS: 49-0003 JEFFERSON STREET
Use classification: S.F.D. Building Permit No.: 0210-311
Occupancy Group: R-3 Type of Construction: V-N Land Use Zone: R-L
Owner of Building TD DESERT DEVELOPMENT Address PO BOX 1716
City, ST, ZIP: LA QUINTA CA 92253
By: G. SHOWALTER
Date. 062/23/04
Building Official
POST IN A CONSPICUOUS PLACE