0111-032 (SFD)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
Date �r6 � -o Signature of Contracto �� 1• J .
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&RC. for this reason
Dote Gignature of Ownor
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 �.;1:+'1�'1'TH INS, COX Policy No. Z041W096
(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.l should become
subject to the workers' compensation provisions of Sec Ion 700of the Labor
Code, I shall„forthwith comply withh.,,th6se provisiol
Date: Applicant- 0�/`f iass..s� . C
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
the above-mentioned property for inspection purpos s.
Signature (Owner/Agent) '���' Date r• tp!
PERMIT#
BUILDING
.PERMIT
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DATE VALUATION ' LOT - i * y TRACTJOB
SITE
ADDRESS 1<! 41`
APN MI. wi
OWNER
CONTRACTOR / DESIGNER / EN (NEER
CMV .L.A Q'IJ3;iTrA 70 L,
CMV LA QUW A I0 LR
- 0(I .. "NASA IN(YAJ34 L�` L
�li0 1n WE4�'CiT(C3��`C�N AVE,
7MM31 DO CA 92023
LISIC0,N-ow CA 92025
USE PERMIT
C�O4�Fy��jjh�yy��yyl}t 77•����yy�� rr 77 �1�,x•(
071L.�'t'�l't,iSrd•.C'L:tU.R.E,r,br LY'V�L.3,Mb�f�'
'
, d a 1,01` 5 .I%'LAN 1C,RILV., PN„RAl't' DOES N()`1' INCLUDE BLOCK:
WAUA 13001 A DPA OR DR.i'� eW.hy' It,p1?n,omm % PLw c1mCaw PV.E. y
it?i ur_ttT,tr i4 voit mumvLa intil lAver v amAn, 9"l.,tl°m Twii
CUSTOM CONSTRUCTION z9a.5.00 SP
PORCHt"r.lA'TIO 355M Si:
13',A%1! QIC: 1'ORT 674,01) OF
EhT7"�, XWD COQ IP C O?�?��v�'�'r�D'C� .101�T .
. 1,4453.40
boy
MMARY
;'t:M'f'RUC'P3c.N PEE 103-000.418-000 $1,)68,00
PLAX MIMICK Me W9.04
MECHANICAL RE 101-000421'-000 �d21;f�t1
fadr ir'awi����Ca i4 E' Y 301'°00"20-000
9'LtMING PEP, 101-000 419-000 $154,7.9
S RONO1,10TI014 AD- R.PIID 1011.-000-2' I C;Cdfs ` 1 $25.05
0--��1l1¢t���.At�tti'�#Cyy3,,yyF'yyk�:.� 101.000.42)-000 �2A,
2T p rnq • ,. �y
A.IR T UN PUBLIC PLACES - 'KERYK ;$7C9 -G00-445.000, �1X 16
Q, c.
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V.969.46
U '33 IIRR�FAID MIS
NOV 19 2W
WYOFLAQUINTIA
IfER9�t�C� Q��. 1
•
RECEIPT
DATE y
/l - !'i - 0 1
BY t
{ �I P
DAT I
INS PECT
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings Q�v�
Slab Grade�/
_
�Z, Lv _ (oLl
g/
Underground Ducts
Ducts
Return Air
Steel
Roof Deck
2/WY
Combustion Air
Exhaust Fans
O.K. to Wrap
Framing
Insulation
s/j�-
�8 jdy
F.A.U.
Compressor
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
s - _
Final � ��3
BLOCKWALL APPROVALS
Final
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
Waste Lines �?i�' �p�
Water Piping
Gas Test
Electric Final
Heater Final
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
/?i�3/�/ (V
Encapsulation
Gas Piping_
Gas Test
Appliances
Final
COMMENTS: /
f�l�
Final
Utility Notice (Gas)
ELECTRICAL APPROVAIZS
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)
Certificater of O:ccupangy.-r C, r
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CIo L a urn to y
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E 4
B dildi gr,",,and.SaMt Department �F
•'i � .. � It � ,� _ �' y�,] :) . 1 - '_i .. - .r ���- ` �
This Certificate•issued purs'uant.to the regiuirements of Section 109 of'the Uniform Building Code,
certifying tha(at the tithe of issuance, this structure was compliance with` flie various ordinances
= of the City regulating construction or:use. For the;following:
r C, w I
BUILDING ADDRESS: -56-023 WINGED FOOTS
Use Classification:' SINGLE FAMILY•DWELLING'. Bldg"Permit No.; `0111-032
Occupancy Group, R73 Jype.of'Construction: VN Land, Use Zone: RL
r
Owner of Building: CRV.-LA QUINTA,70 LP Address: 200 E. WASHINGTON AVE
City:'` ESCONDIDO• CA 92025: y
B DANIEL P. CRAWFORD JR. rK
tDate:;, 4/30/03 k
Building Official - -
r i POST IN A CONSPICUOUS PLACE