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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 qff9ct.
License # Lic. Class xp. Date
.. //,/
DaIA? -r% Signature of Contractgr�""�'u
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
( ) 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.
i�.d(4Cr�'IC �!,taCl•:1✓",'.�33., �1i�Q1CtU
(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 ma/ne,s as become subject tithe
workers' compensation laws of Californi• agree that if I shorlid ecome
subject to the workers' compensation pro ns/�f Section 700go Labor
Code, I shall forthwith comply with th �e IoJirbns. r 1
Dater Applicant <• °'� 1
Warning: Failure to secureWorkersV ompensation 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 inf rmation is
correct. I agree to comply with all CI Y, and State laws rethilati t he building
construction, and hereby authoriz, rrep esen tives of s it o enter upon
the above-mentioned property for'ns actio; purposep"
E-00, » 4
Signature (Owner/Agent �' - '� Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT �.(,�� TRACT
V7 r- Y77. ) 42 'A9 5 -2
JOB SITE
ADDRESS_.
APN
1_�c�Y 1��
.�, vH .W.cte, ■,J�
76,24390-Wl
OWNER -'
CONTRACTOR/ DESIGNER/ EN (NEER
8.1'a13, I,..LC
ffiiM OF 3`ra%&ORNIA WC
1694 0 V014 KAR AN AVX ..Y, 20£0
23 CORPORAM PLAZA SME. 24.5
:tI"€'IRNI C. k 92606
k•TEV` OR.T SEACT:i CA 92660'
(949)7r 1949`5 MLO 6364
USE OF PERMIT
P001AR& OR DW9ilW1APP ROACH. 1% I'i.AN CHECK M £E,MU'CTIOW
FCDlR 1115 iVICZ OF SAME KAN TYt'PEe..
CUSTOM CONSTRUCTION 2,.110.0 ar.
Mkd:HIPATIO 520.90 SF
FS12WOM C05"Y 0 ? CCsmmuciaox
247,0 AO
MWITMIT, RADIO=
CONSTRUR"'ION YU 101-000,418-000 3js.140,00
P"9:h1 Mile ✓y: PE? r 101-.000-439-318 sm.05
MECHANICAL WE 10`1(.000.423.0, $ia ,00
E'.R.;eC'M11C1.la£. PEF, 101 -(Y00- 420-000 $16£.6:3
PLUMBING MAE 101 -WO -419-000 $143.13
S"1'it;?M MOTION' F� X - it ESID 101-000-241-000 $34.31
CUOMO RE 101-000-423-000 00.423.000 920,00
£3FVT+2,0PER W1'AfrT M.F., $1,90. ov
ART I'N PUI3WC PLACES - RES11270.000.445.000 SI�15.l0
1
SUB -'E`aI'4Ld COaM3RUC.1f701T,3►,TWPa CREC£C
e a t ', '�17t� ITEM
�iC1
'TOTAL I�:�" Iras1D�'I.�,� Now
SEP 1 1 1001
CITY OF LA
NAN E DEPTUINTA
a
RECEIPT "'At,
DATE d
BY1
D TEF D `per
I ECT
/.F. /!«.r•/
it?/`
_ ,
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
- -
Underground Ducts
Forms & Footings
/p�
Ducts
_ _
Slab Grade
`
Return Air
Steel
Combustion Air
Roof Deck
�?j�� 6
Exhaust Fans
O.K. to Wrap
_ _ d (�%
F.A.U.
Framing1�2
(�
Compressor
Insulation
�! ' cf 2 �/
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
BLOCKW
- 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
_
�p�9�6/
Electric Final
Heater Final
Water Piping
/
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Parts
O.K. for Finish Plaster
Sewer Lateral
_ _
Pool Cover
Sewer Connection
�r7�9! 6
Encapsulation
Gas Piping
Gas Test
�jlS U%� �ptij
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
—
L -O -
i
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)
,. Certificate of Occupancy0 o
C�
OF 'T1 Building Y p & 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: 81-295 GOLF VIEW DRIVE
Use classification: SINGLE FAMILY DWELLING Building Permit No.: 0109-063
Occupancy Group: RR=3 Type of Construction: VN Land Use Zone: RL
Owner of Building: SRHI, LLC Address: 16940 VON KARMAN AVE, STE200
City, ST, ZIP: IRVINE, CA 92606
By: BILL GORDON
Date: 12/4/02
Building, Official
POST IN A CONSPICUOUS PLACE
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