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LICENSED CONTRACTOR DECLARATION
1 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
71.1188 R 10131`97
/Date 11bJr197 Signature of Contract
GOV
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1, 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).
() 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 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 Se tion 3700 of the Labor
Code, I shat ffo�rt�hwwiith comply with thos provlsl r1S.
VDate: �� . ' 7Applicant
y�
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..F
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 2
the above-mentioned propertyfor.inspect(on purposes.
Signature (Owner/Agen - Date ///,
4/it
BUILDINGPERMIT PERMIT# CONTROL#
" 92DATE VALUATION ' 0�5 TRACT !X) LOT �, s ?
A DRESB SITE fSURT APN � a 1�
ADDRESS U
OWNER
01-IMP111.;Y C:ROfib"ELL CC..MMIL1"a: t 4;:S
1515 Sia. "D* 511ML1; FrE. #7t)il
NAN HERNA1{ONO CA 92,109
USE OF PERMIT
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CONTRACTOR/DESIGNER/ENGINEER
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1535"0"
SAN ki1il+;i ARI)IN0 . CA 9biUR
t<))3Ri•t�d)f)� C�1f1,
'2120,
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36 +1+3 SF
4t,1.490 :its
fltV1TJ ,AT,C0NS'IVI.ICT'I0NANt•>PIAN C11V(
i..1;rx`r 1'I.1i-f't'.1Fi t I:l.S $0.00
'IfffA!,1'FRN11T P%Io:S DUC iv0W
Nov 10 1997
RECEIPT '• + \'-T—DATE,.—_ ! BY f DATE FINALED INSPECTOR
Pta.kMIT PCE, SUMMARY
PLAN t t114,CK FEE
104.0)0-430.318
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C�`iNSTRIIK'l'1r')N 9-T
101490)4118-001)
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f0lf f1hKif�if)€0i,?t+iTri?f?
11)I.1000- 'x•01)0
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ftJhitAt:J'f�lrt;(i!►tist'd_!;
x`15 -0h) -*43-'342
$f,f+Fi7,1t
e:
fltV1TJ ,AT,C0NS'IVI.ICT'I0NANt•>PIAN C11V(
i..1;rx`r 1'I.1i-f't'.1Fi t I:l.S $0.00
'IfffA!,1'FRN11T P%Io:S DUC iv0W
Nov 10 1997
RECEIPT '• + \'-T—DATE,.—_ ! BY f DATE FINALED INSPECTOR
r
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
Set Backs
Footings
Forms & Footings
Main Drain
Slab Grade
Steel
Roof Deck
-a,/-
O.K to Wrap
Framing
q' -
Insulation
,
Fireplace P.L.
Fireplace T.O.
Party Wali Insulation
Gas Test
Electric Final
Party Wali Firewall
/
Exterior Lath
Water Piping
Drywall - Int. Lath
J_ _-r
OPERATION DATE INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U:
Fans & Controls
Condensate Lines
Final
IV I_ -
BLOCKWALL AP ROVALS
Final
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. 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
COMMENTS:
Im
.....,.,
ELECTRICAL A04PROVALS
Temp. Power Pole
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
.Temp. Use of Power
r
Certificate of Occupancy
City -of La Quinta
Building and Safety Department
This Certificate issued pursuant to the requirements of Section 109 of the Uniform Building Code,
certifying that, at the time of issuance, this structure was in compliance with the various ordinances
of the City regulating building construction or use. For the following:
BUILDING ADDRESS:
Use Classification: SFD
79-170 DESERT STREAM DRIVE
Occupancy Group: R 1 Type of Construction: VN
Bldg. Permit No.: 9710-126
Land Use Zone: RL
.Owner of Building: CENTURY CROWELL Address: 1535 SO. "D" STREET, STE #200
COMMUNITIES
City:. SAN BERNARDINO, CA 92408
By: STEVE TRAXEL
Date: 4-17-98
Building Official
I POST IN A CONSPICUOUS PLACE I