0109-051 (SFD)U)
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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 e e t.
License # Lic. Class p. Date
ola
Date C "` � Signature of Contrac�r
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:
Cartier Policy No.
PAcr970 ItAq.11Z T.40. 430I01127'1
(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 mannefso as to become sub0ct to the
workers' compensation laws of California„an�'ag a that if I s pId become
subject to the workers' compensation pro?i ons f Section of the Labor
Code, I shall forthwith comply with t�,pt`ovrons.
Dater
Applicant! f
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 C/SY_C,t,PS
d Slate laws rel I E to the building
construction, and hereby authorizee�{atives of t is ity to enter upon-.
the above-mentioned property for i fl purp e
r ` U.
Si nature (Owner/A ent) Date ”" A �'
BUILDING PERMIT PERMIT# 1
DATE VALUATION LOT t)'j0,9-051 TRACT
?ate '17s�d4i - 23+ 81Ri 1.2
JOB SITE
APN
ADDRESS., -�-
1-: G{JL'.f.+' VMW urdVe
OWNER
CONTRACTOR / DESIGNER / EN INEER
swix, <[a c
SHLR 0, C°AUXAMWIA INC
1694 0 WN KARMAN AVE 7M 200
23 CORKYRA.3E PLAM SUfTX 245
CA 92606
'�,�'OR7 �i 41-1 CA. 92660
(949)1'I94TIS CBT,1't 6314
USE OF PERMIT
3IPT) , LLT .23, PLAN 75h. PEIOM')^ Tat XFS NOT :.N.CLUD1»' 'BFOyr,
WM A I-VOIJ3PA OR IP><UVEWAY APPROACH
CUSTOM CONSTRUCTION 2810.00 $Fr
)aMC HIPA71 IO 590.00 SP
GAR.A01?8'CARP43RT 789,00 OF
.di}'I S.�Lt�' ,A�.7 D 67'1JS �. Y RJVd.rBY.M1.E WsPF&.O
.•64.'2,07 .49
p�'j(igyyy �y��+9j (�gY 77'(� �.
.l�,YStkAG.1E".3 r 1'��.Y E Si?J,7.�1`✓.7LidXY,
CONSTRUCTICF34 )` IC71<CIt1fI^»9i6wtIIf1? 59.,240,�va
PW14
MECHANICAL FEE I01-000.421.000 $124,00
I =TRFC:,M., PER 101-ilOi'1 20-C°00 $166,63
P1eU101'Pdi1; ;`IP,X 101.000.419-000 5101.75
S`I"RDNO 3dd2)'g'ION FFZK - Y.'.HOID 1601 -0004A.1 --DCO $29.21
(IRADIN(. FEE. 101 -i 00.423.0CM SX00
0,XVZLOPER 1IMPACT M $1,907.09
ART IN PtJlsW KAACL?J% - RWE rt"00.445'-000 910111.0
aC)`A- OTAL C O -AT 1:F.�.'F'GrION AM.) P9:,,.AX Cl'=X
$4,E16. 98
LOS PRE -PAW IW'S
$0.00
D larAl �1PEE'! Is a,�.
t12]10-
SEP
CITY OF LA QUINTA
FINANCE DEPT. _ x.
RE
DATE
DA I AL
IN ECTO
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INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
_
Underground Ducts
Ducts
Slab Grade
_ _
�6��/
Return Air
Steel
Roof Deck
/l/�6 ��
Combustion Air
Exhaust Fans
LOOi
0. K. to Wrap 1i _( _ .0/
6� /a _ _/(/
F.A.U.Framing Compressor
Compressor
Insulation `�
%-2�/�L -
Vents
_ -
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Cond sate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
f=inal
Final
—I
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
!�/�fi����
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
Encapsulation
Gas Piping
Gas Test
Appliances
j
Final
COMMENTS:
�
/67 / X162
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 PowerVA
Final
— V ll4
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Utility Notice (Perm)
Certificate of Occupancy
V - 5.II,,II
4
(Lrn 9 antra
G OF'Ti9�7 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: 81-300 GOLF VIEW DRIVE
Use classification: SINGLE FAMILY DWELLING Building Permit No.: 0109-051
L
Occupancy Group: R3 Type of Construction: VN Land Use Zone: RL
e
Owner of Building: SHRI, LLC Address: 16940 VON KARMAN AVE. STE 200
City, ST, ZIP: IRVINE, CA 92606
-� By: BILL GORDON
Date: SEPTEMBER 12, 2002
Building Official
POST IN A CONSPICUOUS PLACE