0111-034 (SFD)44; 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
Dat `'��'"� Sig nature of Contractor��9
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
DAW, ' Signaturo of Owner.
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the.following declarations:
( ) I have and will maintain a-certificateof 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.
. N71) 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' ZENITH INO. Policy No. 79423.945H
(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 1• should become
'subject to the workers' compensation provisions of Section 3700 of 4thLaborCode, I shall forthwith comply wityttiga'e>provisions.1
Datej%" �W'C�/ Applicant 1fc,.(✓ jam'
—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.37061,1
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.
j 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 )4°t'°��'"" rA'� `- Date
- BUILDING PERMIT PERMT/t
DATE VALUATION ra'z?4ssF � LOT TRACT
JOB SITE w
ADDRESS 56.^ 31GET) FOOT
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
Nell `4N,MIRRO'1°O INVE,
200 K VIA•`.1Z`s'3]RIT ON AV
322OO��:r I 0 CA 9.2025
1±`. CON-D.%DEi A 202
CSIP $4121
USE OF PERMIT
a:ks't3. 1/.)T"P PI.QAN 2Q. ;PE;f2AtTT LiO k+ Ul' )'i+t'C'LUi,19 K.t.)ICK 'WAi!.,E...'.
04 DRIVEWAV APPROA-CH ft, PLAW C:Hf CYC M !1_0.)} IC''' 10il
6roy. MU8.TIPIA, OF SAME PLO TWPI
I
CT4�t�p3�.aySTKOC:` ON Man
'.Y.glgSp'pCOy1}�/1� {tyxl,,
ESTI..k4!3'NI1'5I) COST OT' a"t?MMUC7tTION'
1W11599160
'li ERM&T,1S' SIMM EtBARY
C'010T.'►,lt]MION VEY, 101!-000-4] B-000 81,3.;€ -00
101-000-4,39-318
MECHAVlCAL, FEE 101-000-423-000
N]�ll ONG Fu 101.000.419-000
; T.R-f3140 MOTION 1'FIX . ] ID 101.000.2411 -No $29.46
(YRAP!?!t3 FEE 92:44
DppOV,Ef}�.'L1rl7�EY�R 19A�!'�5.F>,i:•yTpt1►n�xE, 1p,9t0s'tr.00�
!A ct� to f �nFy
rt&iif YN i'47.dRa1�� ➢'"X.rr�S:l�.M,
',
NOV 1 y ��1�1 1:.,13 5 �g PAV) RM
$010 a
pp/[��4(y
t. 111JU].l@y RJ. J�"b'I.G.- tY DU Tf NO
WYORAQUIN
FINAMPF �i�
p{�
94,33 l✓:R'8
RECEIPT
DATE
11„ lC/-c
BY
(� , .
DATE NA D
a3
INS CTO
X
INSPECTION RECORD
OPERATION
DATE
INSPECTOR OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs_
Forms &Footings ���
_
QDucts
Underground Ducts
Slab Grade
y-,yw 61c/
�ii
Return Air
Steel_
Combustion Air -
Roof Deck
_
Exhaust Fans
O.K. to Wrap
Framing
_� _
Q�-
F.A.U.
Compressor
-��
Insulation
��9� ���
Vents .
Fireplace P.L.
Grills '
Fireplace T.O.
Fans & Controls
Party Wali Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
_
lizAn}
Drywall - Int. Lath
Final
Final
3
_l'j0
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS,
Gas Test
Waste Lines/$�
_ _
/
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
��(��j.L (/
Encapsulation
Gas Piping
Gas Test
_
Appliances
Final
COMMENTS:
Final
�j���07�-
Ll� 61q
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)`
tiflca•teOf 0d c' '_
-1•;'S .... 4 } ii '-.- ! ,. '• ,r �;any,. .. - � Q ��
;{of,La :Quanta t
iT
BdildingandSajfety0epadmcnt:,�MOF"ti
L wJ; - --' It� .• f -j
" This Certificate issued pursciantto..the requirements of Section J09 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-7?.. -56,031"HINGED FOOT �?
Use Classification: �,- SINGLE FAMILY DWELLING Bldg. Permit No.: 0111-034• .- ►.
_ .
-" Occ_upancy Group �R-3 Ty pe, Construction: '- VN Land Use Zone: RL
Owner of Building: , CRV,LA QUINTA 70L•P' r Address:"x200 E:,WASHINGTON AVE. 4
_ City.y ESCONDIDO, CA 92025
By: DANIEL P. CRAWFORD JR:
Date: 5/7/03 S
Building Official
POST INA CONSPICUOUS PLACE
.. _' 7 • ` \ ` � �3. , ,. �� l'� r uy � •S � r. L, /"� ',- i' � , t i r. � _ 4• , ", .f W � ' ''` K'