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LICENSED CONTRACTOR DECLARATION
I herebyaffirmunder 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
787856 :8� I1131012(
,rDate
—7/1F41, t Signature of Contractor -rte �A
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 Policy No.
MAiROM 4754, DIC CCN01494 10.2
(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 l shall forthwith comply with those provisions.
te- ' Applicant
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 ihat 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.
-�"
S66ture (OwnedAger - "r� a � �' ate ��;° �%
BUILDING PERMIT PERMIT#
DATE VALUATION LOT E11()J,.30% TRACT
t3m:n rj a 54'
JOB SITE
ADDRESS
APN
81-175 GOLF V}tW D TVF
7621-280-017
7
OWNER
CONTRACTOR/DESIGNER/EN (NEER
c` %1 R (YJF CA1.9-V 141A WC
TI" , OF C,R►'(.1.1"fr1t91A INC
23 COUIORA'.fi.? PLAZA M TE 245
2,1 C0P%PiRXPIE I'Y A % 4=13,245
CSA 97660
N:1 W009 U-40.1 CA. 92660
+�949�7I -45'1 C'I i% Q&4
USE OF PERMIT
9:OIGIX, FA: &LY 1:+'4V=240
S1Md)1.,t3N. 0A WCASIT,lR f,0 f d-l"%1Z; f1 1 Sr` �; 3dZ39° 1Nl I ia1 k,
i Int? I a T,tn�Ff� (1� FZl f Vd �' APKkCiACK
CUSTOM CONSTRUCTIOW 310I6100 OF
1;CRn:HIRATIO 912,0 SP
CdAi%ACIFICARP(.1RT 150.00 R -Ir
X&''� WWfJ9X) COST OF 4`#;,1:N91`8:UC 1°I0N
'324,'7.26.00
(s4):IXURUCT 1ON FRE 101.000.418.000 S1,W.00
KAIM CHECK "F 1011,000-439-318 11,151.01
T1iSs% kl a dIZ`,�+ils I43 101.000422-000 $124,00
EkdG1RtAL, FVE 101-000-4241-0W $9037.06
P1.,UMBNO Is 101-000.419vOM, S199.11
—°S°P1a.C:3NO MOTION Vii: - RESID 101-000-241-(W $32.47
ORADI O FEE 1ill-01JS)-41.'1-kXKJ $20,50
KWIVY10AMR, IMPACT ss)REF $1,�JfD7.Oft
,ART IN PUSSIX PLAC'`ES r K9811C 701 -WO-2$5 0€ 0 $311,52
...J
T3 1`�,`.lAti d`J.°d.L.+P.'',�.eR'1.7.`d 6ti k�.C�5..10
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4' 1,71 i.Y 1:
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PO&ff MS �a>i%.I NOW
V :YI7A 1JUL
2
CITY OF LA OU
ECEIPT
/ Y I
DATE FI ALED
I ECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
_Underground
-1
UndergroundDucts
Forms & Footingsvl�
? _9� _ _
Ducts
Slab Grade
p�
Return Air
Steel
Roof Deck
_
9!�(b
Combustion Air
Exhaust Fans
O.K. to Wrap
16— - Q�
F.A.U.
Framing
_
Compressor
Insulation
�Q �j�_t
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
S�/3�oa J�iGI�Gj_o��•.
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
Gas Test
Waste Lines
_
�19/g
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
_ _
��/f,�j���
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Vottage Wiring
Fixtures.
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)/�7`vZ
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
ollowing.
BUILDING ADDRESS:
Use Classification: SINGLE FAMILY DWELLING
81-175 GOLF VIEW DRIVE
Occupancy Group: R-3 . Type of Construction: VN
Owner of Building: SHLR OF CALIFORNIA CIN
Building Official
Bldg. Permit No.: 0101-305
Land Use Zone: RL
Address: 23 CORPORATE PLAZA STE 245
City: NEWPORT REACH, CA., 92660
By: BILL GORDON
Date: 5/13/02
POST IN A CONSPICUOUS PLACE