0303-117 (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
Processionals Code, and my License is in full force and effect.
License # Lic. Class } Exp. Date
64rTA 6P30/03
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 NA'P4ONAL UNION 7 Policy No. `'033"9
(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' compenaTtionliprovisions of Section 3700 of the Labor
Code'; I, shall oLthwith com ly with those pr6i'g• rrg.
spate: � i Applic t " �
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,atr
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 ar`d 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.
S rig (Owner/Agent) "� Date'
PERMIT #
BUILDING PERMIT
DATE VALUATION'S LOT �lSg TRACTJOB ��
ADDRESS CAED Ceti FL i S'C� F
APN
7CW-270-0118
OWNER
CONTRACTOR / DESIGNER / EN (NEER
6.0-: '1 i 'f31Ztf i 4Y P,%u 3Vl�iY
€1,1.426x0 AVMT IE 62
T�ko(If rl` . Ch 92253
f110.1�AL
C`A 91883
(909-)833-896
CBVI 6876
USE OF PERMIT
3'111 a 1.13.1' 103, a✓ Fit 43;UL; < L5.C41UZ 4,6"F. 05 Zi.1r..At PitI'A; Jl -
90 9. Y.) PERMIT Lit &S NOT INCLUDE IILOCK WALIA P004 SPA OR
DI'.Niri✓ AY,APPROACI-1
(I L> f, 5
Vi/B'I OM CONSTRUCTION UAW 317
PORCHMA170 427.90 Sr
0AXAOWCARPORT or,
2S1WJA'1`.4? D Car 0:0' C0N9n;eI C170.N
1.3518Z11130
P f"IM111 F121' SUMMARY
Ct NWYRUCT€O14 THEE 101-000.418.000 5765,30
PLAN CHSCE: VEZ 101-006-439-318 $¢93.03
MECHANIM, FZF. 101.000,421.000 $36.50
EP::'VMTR1CAL FEE 101-000-47,0-000
PLUMBING �''E •101-004-419.001 $1I�,t10
STR•ONQ '6.40=14 FBE - RP -SID 101-600-741-000
GRADD40RE 1f}lti(1ti9�d2S�Ofl0 $iS,Ov .
11r.V 9L0PZR 1MP hCT FEE $dflS.CiD
FEE DEPOSIT 101-W0.4394318 470.00 .
S1B3 `MAL CVM7'1.1"'2Ut-1-1014 ,AN33 PlAIS' CHE(W
$4, 124.91
IMS PR&P U) FHE3
47.50,00
r , TOTAL PL, PJ1V' :1 S -OW 3V€ W
s 4.
MAR �.. 2��3�`
CITY OF LA QUINT
FINANCE DEPT.
RECEIPT
DATE+ ,
' 2
BY
1�
DAT FINAL
INSP
INSPECTION RECORD
---,.--OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings 77
Ducts
Slab Grade
Return Air
Steel A
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap D• A
F.A.U.
Framing
Compressor
Insulation N S D
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS -SPAS
BLOCKWALL APPROVALS
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 ConnectionEncapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
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)
IDMainiero, 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 #
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
123,1
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
60-431 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
16,
60-392 Lavender Court
�432.5G
432.51
+ 0.01
162
60-414 Lavender Court
432.20
432.20
+ 0.00
V163
60-43 avender 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
1428.50 1428.52
+0.02
Very trul yours, 0 SAND S
STEVEN J. VAN
Steven J Va , L.S: 6500
I REG. EDX
SJV:tt fJ N0.M
cc: Hector Guzman, Engineering Department q�F OF C
Mike Groessl, Shea Homes