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_ - LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Professionals
hapter 9 (commencing with Section 7000) of Division 3 of the Business and
Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
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.
(t) 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 Policy No.
(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: I YApplicant
'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 work4or 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) F - �' .: ' rx. Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 0301146). TRACT
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OWNERQQ CONTRACTOR / DESIGNER / ENGINEER
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RECEIPT
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INSPECTION RECORD _
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
Plumbing Final:
Equipment Enclosure
BUILDING
APPROVALS
MECHANICAL APPROVALS
Sewer Lateral
Set Backs
Pool Cover
Underground Ducts
/,/
Forms 6 Footings
fj p
Ducts
Slab Grade
— -
Return Air
Appliances
Steel
fes- -
Combustion Air
Roof Deck
Final
Utility Notice (Gas)
Exhaust Fans
COMMENTS:;
O.K. to -Wrap
_ - y
F.A.U.
Framing
Compressor
IJ
Insulation
_ $ 5'
Vents
Fireplace P.L.
Grills
I+
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Druwall _ Int 1 nth
'3_ _ k .e
Final
BLOCKWALL APPROVALS
Set Backs
Footings
Bond Beam
Steel
Electric Bond
Main Drain
Approval to Cover
Equipment Location
Underaround Electric
POOLS - SPAS
PLUMBING
APPROVALS
Gas Test
Electric Final
Waste Lines j
//
Heater Final
Water Piping
Plumbing Top Out
Plumbing Final:
Equipment Enclosure
Shower Pans
OX for Finish Plaster
Sewer Lateral
A,
Pool Cover
Sewer Connection
/,/
Encapsulation
Gas Piping
_ 7�
Gas Test
Appliances
~
Final
Final
Utility Notice (Gas)
COMMENTS:;
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
Win Notice (Perm) /0 —
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Certificate of Occupancy
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OFA 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: 79-883 DEREK ALAN DRIVE
Use classification: SINGLE FAMILY DWELLING Building Permit No.: 0309-169
Occupancy Group: R-3 Type of Construction: VN Land Use Zone: RL
Owner of Building: PM RENAISSANCE, LLC Address: 9968 HUBERT ST. #102
City, ST, ZIP: SAN DIEGO, CA
By: STEVE TRAXEL
Date: 06-03.2004
Building Official
POST IN A CONSPICUOUS PLACE