0303-113 (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
� c934
13 C 6130103
Datek �, I ' Signature of Contr
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 NATIONAL UNION F Policy No. 7083309
(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 thea workers' compensation provi iorR?,of Section 3700 of the Labor
Code fiall o�rthwith compl6it�thosre pr vlis(oCs,,J•
Dates 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 employest
2. Any permit issued as a result of this application becomes null and voi(lif,
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 cancellati
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 bulldmg
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned pproprtty�for iris�pection purposes.
Signature (Owner/fgeni) ' Date`°i5%
r
BUILDING PERMIT PERMIT#
DATE VALUATION $146i :MMO LOT' 1� TRACTJOB SITE
ADDRESS L%�+J�. �.ir.�JS. APN
OWNER CONTRACTOR/DESIGNER/ENGINEER
Lf't3mI.A. QUT13n\, 7 J c S1 KA HOMES
81.260 MtWUE tat
1e QlT,fr rA. CA 9 253 7TRUL'", CA 92883
(9090833-8996 CEWI 6576
USE OF PERMIT
SYD . LOT -159 PIAN 4530.8..PERt.lCT DOES NVr rNC.'LUDH BLOCK
WALLS. P0014 SPA OR DRIVEWAY .PPk?OACT.
GCS 1
CUSTOM 0ONOTISIUC:1'ION 111.00 3F
POlxt "A.TIO -34.00 Sty'
mvX.Cmd6`K.11 con or 9aows '~ ucnon
146,35-47.70
1 ERWrr-T3a.E SUMMARY
CONSTRUCTION MR.
107-000.418-00()
$804,00
CHECKltt'FE.E
�+1�;Qys��»�r3f
$R643.9l0f
�PLA�314 tP�tK,
�11dA..r7A'AeQL�i.P"1L E
a9-f3�18
q1. e0y y1
101-000-421-000. ,
ai MiD
CL.ECTRI MAL FEE
101-000-420-000
11031.92
P1<{M) rNo F'EC
1$116.78
S'Pr:P.'iNG MOTION PZ7B. RESID
101-000.241. 00
$14.63
:GRADINCI PER
101.000.423-000
$15164
Ol?V11IDPER IMPACT FEL
- A405.09
TME DEPOM T
t 01.000.439-318
�, _rr o,00
HUs' -TC1` AT CP1 1RUC:CION.O AND MAIT C_T-)i7 $4,138.70
LESS PRE -F F1?& ' -$,750.00
W 0,408.70
MAR 24 2003'.
I
CITY OF LA QUINTA .
FINANCE DEPT"
RECEIPT DATE ± BY :ADq FINIL INSP
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
I
Underground Ducts
Forms & Footings.444
4Z
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
$1 03 10
Exhaust Fans
O.K to Wrap
F.A.U.
Framingm
,p
Compressor
InsulationZ�W WiA,(1402,
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
44a 4
Drywall - Int. Lath
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 Ij
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
Final
LM14 Notice (Perm)
COMMENTS:
Mainiero, Smith and Associates, Inc.
�110Planning / 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 #
. 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
607431 Lavender Court
431.70
431.72
+0.02
V159
60-407 Lavender Court
-- 432.20
432.23
+0.03
160
60-387 Lavender Court
432.50
432.51
+0.01
1 161
60-392 Lavender Cour
432.50
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
1428.30
428.33
+0.03
166,
60375 Chelsea Ct
1428.501428.52
+0.02
Very trul yours,
Steven J Va , L.S. 6500
SJV:tt
cc: Hector Guzman, Engineering Department
Mike Groessl, Shea Homes
S�,;� OND SUNG
STEVEN J. VAN F�
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