0303-115 (SFD)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
004 �� 0f03
Date ' Signature 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 HA Q14AL UNION F: Policy No. }1�8$3fl0
(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 df Section 3700 of the Labor
Code; 1 `hall fb hwith comply `with `those,provisionS.
Date; '( ^� 1 h PI 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 above-mentioned property for�inspection purposes.
Signature (Owner/Agent t) -^--- Date
PERMIT #
BUILDING PERMIT 5 ,
DATE VALUATION S2,29.748.80 LOT. • -161
<�
JOB SITE
ADDRESS 6a-392 LAVENUM COL +
APN 7&4-270-018
OWNER
CONTRACTOR / DESIGNER / EN (NEER
60-311 XXL)OCYY 1-'AR:K lA*f
91-264 A U R, 62
LA,Q'U- TA CA. 92253
Tlw. I "l+1J kL CA 92983
(909)833.89%,, CBL# 6676
USE OF PERMIT
1
012 F.0,MY DWEP:Z'I O
SK) .1.01' 16.1, Y1.A 155:y.tr. &11411K .a.AY .-Ads.r.)
PERMIT UOKS NOT 51CLUDE BLOCK WALIA POOL- SPA O DRIVE -WAY
APPP-O.ACH
CUSTOM CONSTRUCTION 4676,00 OF
rtO RCHIP.ATIO 498.00 Sp
GAR&OWCARPORT _"3100 SP
X9=X . COST: OF CORMNUCHON
23,9,74820
x'] RhM FX%u SUMMARY
C014STRUCTION FEE 101.440.418.000 SI,094.0
PLA14 CHECK In .101-000-1439-3t8 sumo
MRCd AIkICAL.FEE 101-009.421,000. 599.90
RL1,CTPJCA3.. PES 101-000-420-000
PLUMOINC3 .C1< 101.000.419-000 $172.00
STRONG MM'10N M - RV SID 101-000-241-0,00 $210
OWING PEZ 101-000-423-000 $15,00
DEVELOPER IMPACT F!rte 42,4.Os.On
ART RT PUBLIC PLACES - R99114,70-000.445-000 $74.
Tif+'POSIT 101-00a439-318 •�TS0.00
90P, -TOTAL C0IT,=L 3'� 1�,i031 ARD PIAN 101-7 ''LC
$4,911.61
�-----�- �-- n _ LOS Pitt- `FMD F r ,
r
-$750.00
t4
, MMMMSDURNOW
MAR 0VJ
$4,162.61
CITY OF L4 QUI,4 A
FINANCE DEPT.'
RECEIPT
DATE; 7✓ ��
BY
DAEpIJA
INSPECT1251,-
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
I 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 6, gap, 0 3
F.A.U.
Framing lwgm
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Finalps.�42
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final I
Gas Piping
PLUMBING APPROVAL
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
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
r
Final
Utility Notice (Peh n)
COMMENTS:
Mainiero, Smith and Associates, Inc.
Planning / Civil Engineering / Land Surveving
777 East Tahquitz Canyon Way,.Suite 301 / Palm Springs. California 92262-6784
Telephone (760) 320-9811 / FAX (760) 323-7893 • e-mail info@mainierosmith.com • www.mainierosmith.com
May 13, 2003
Department of Building and Safety
CITY OF LA QUINTA
78-495 Calle Tampico
La Quinta, CA 92253'
Re: Form Certification
Tract No. 30023-2
Construction Sequence 1-E
Gentlemen:
This letter is to verify that the following building forms have been checked for elevation and
horizontal location by Mainiero, Smith and Associates, Inc. and found to be in substantial
conformance with the approved Precise Grading Plans. Finished floor elevations for lots 121 -
126 and lots 157 - 166 are as follows:
Lot # '
I Address
Plan
Field
Difference
121
81-687 Brittlebush Lane
431.80
431.78
-0.02
122 •
81699 Brittlebush Ln
430.80
430.75
-0.05
123,
81711 Brittlebush Ln
429.70
429.62
-0.08
124
81723 Brittlebush Ln
429.00
428.98
-0.02
125
81735 Brittlebush Ln
428.30
428.27
-0.03
126 '.
81747 Brittlebush Ln
427.60
427.62
+0.02
157
81-858 Brittlebush Lane
434.90
434.92
+0.02
158
60431 Lavender Court
431.70
431.72
+0.02
159
60-407 Lavender Court
432.20
432.23
+-0.03
160
60-387 Lavender Court
432.50
432.51
+0.01
1 161
6073921avender-Court
432.5E
1432.51
+0.0-1
162
60-414 Lavender Court
432.20
432.20
+0.00
163
60-438 Lavender Court
431.70
431.70
+0.00
164,
60419 Chelsea Ct
427.80
427.84
+0.04
165,
60397 Chelsea Ct
428.30
428.33
+0.03
166 •
60375 Chelsea-Ct
428.50
1428.52 1
+0.02
Very trul yours,
Steven J Va , L.S. 6500 '
SJV:tt .
�i
cc: Hector Guzman, Engineering Department
Mike Groessl, Shea Homes
S�0 SAND SUNG
STEVEN J. VAN F0,
v
REG. EXP °3
N0.6500 Q
OF C A��