0401-107 (SFD)V)
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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
205031 A 436 C42 I`I:� 11J30/7.t
,./Date- c r Signature of Contractor
I
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 STATE FUND . Policy No. 1SM.5
(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: t Applicant V<
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
t�.above-mentioned property for inspection purposes.
Signature (Owner/Agent) ��y' Date -
BUILDING PERMIT PERMIT#
04tl1-107
DATE €i1114. VALUATION �7,.i4t4,9() LOT 20 TRACT 131X 177
JOB SITE
ADDRESS �S-•100 AYJ?NWA 1)JAZ
APN 774-042^
OWNER
CONTRACTOR / DESIGNER / EN (NEER
3M NIO B=,rAP
rKNI C. BEL'KNAP, JZ
P.O. BUX297
73-300 F1DDLD4 ECKLANE
PALM DESERT CA 92261
PALM DMEWT CA,, 92261
1
(760)777-9572 M114. 2905
1
USE OF PERMIT
WKIG1L1;2�A a T1 1I7T.;i l ei£#
1604 3.:P. SF73i, PZRW.JT DORS 1407 .1XCI.Ur*; SLOCK WA IAL, .POWSPA
OR DRIVE A'F APPROACK 75IK KEDUCED FR1s E1OR MULTIPLE PW4
CHECK Or S&ME PLAN TYPE,
TRACT CONS TR'CIC9'ION 1,604600 SY
POP~ CH1PPiT10 117.60 Wr
0ARAt3ttfCARPOR'C 446,00 SF
E57.MIVIIED COfT or C:iDSTI rRlJC"t:[ON
97,394,90
PF -RAC C FEE x UIVIII Y
CONSTRUCTION IZE 101-000-418-000 $630150
PL 14 CHECK rM 101-000-439-318 $131.64
FGF, DEPOSIT 1131.000.439.318 -4I30,00
MKCHATITCA1. OFF, 101 -OM -421-000 $65.50
RUCTRI1:AL FER 101.000.420.000 $1131,56
PLU M01140 YKI* 101-() -4 19-000 $124.00
STRO 10 MOTION FEZ -1101 a 141.000.241.000 $9.'14
D A01NO VEY, 101-000-423-000 $15.1K
DEVELOPER. IMPACT FEE VIA05.00
PREC1SH, PL.AVI 101-000-441-345 $100.100
SITS TOTAL, CO_KS RUCT'iON AND PT AN CD',tsc:."K
$3,594.94
1X33 PRE -PAM FJFSs";3
-:$250,01
n TOM PERM -FEES 3:�L1C NOW
$.%344,94
JAN1:
CITY
F1�• 1/
RECEIPT
DATE"` / ff v,f.
��` �`�
DAT FINAL D Ov
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
I INSPECTOR
OPERATION
DATE
I INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
`, d L
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
SteelCombustion
Roof Deck
C�Q ,
Air
Exhaust Fans
O.K: to Wrap
7
F.A.U.
Framing
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
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
Waste Lines _ ��Q
Gas Test
Electric Final
Heater Final
Water Piping
_
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
_�Cf GC
Encapsulation
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) �f
Certificate of Occupancy
T4&f 4 4 4"
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: 53-100 AVENIDA DIAZ
Use classification: SFD
Occupancy Group: R3
Owner of Building: JAMES BELKNAP
Z�2�
Building Official
Building Permit No 0401-107
Type of Construction: VN Land Use Zone RC
Address: P.O BOX 297
POST IN A CONSPICUOUS PLACE
City, ST, ZIP: LA QUINTA CA 92253
By: KIRK KIRKLAND
Date 6-7-04
*SIadden-Engineering
.:
6782 Stanton Ave., Suite A, Buena Park, CA 90621 .(714).523-0952
39-725 Garand Ln., Suite G, Palm, Desert, CA 92211 (760) 772-303
FIELD MEMO.
Project Name Cl I Client:
Site Address 53
(Af
Job Phone
Work Done T
Test Summary / Foptings Inspected
001153
Fax (714)-523-1369
Fax (760) 772-3895
Date 2-
FROWIM
Comments
Field Tech.
or Agent
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Field Tech.
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