0012-287 (SFD)rte- 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 �g
Date ,Signature of Contractor
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 isl4issued. My workers' compensation insurance carrier & policy no. are:
Carrier, Policy No.
(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, I shall forthwith comply with �t'h'ose rovlsil 'S.– —,
f'
Date: -14 Applicant-
.w•'TT .�ti a°t'�+'' -.. `.%/.•e :o' .! .F(,.,.,.,
Warning: Failure to secureoWorkers' Compensation coverage is unlawful and
shall subject�an employer to criminal penalties and civil fines up to.$100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's,fees.
IMPORTANT Application is hereby made to the Director of Building rand Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made& each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued:as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.. f'
Si nature (Owner/A ent) �� -Date /-2.- 4 �.
BUILDING PERMIT PERMIT#
VALUATION LOT TRACT
DATE1.��hy
m¢y1.�/yM} y ) N! ¢Rp�e9 y a¢�
74 298N_14
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR /DESIGNER / EN INEER
MER OF C L 1<rORNM INC,,
MULYHOIV1041, INC,
(9,49)7 ',19-4975 CW143 5337
USE OF PERMIT
a#?.�C11..�.:�+/.=rl.'l1.kT.Y 3:i•i.,�.,12�i'Ci
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Sin PLAN—M l..OT:24-I'E3bMIT VORS NOT Iza��,�r.�=�
.tlD0'.` AURrJrr+LID IVIL AYrPPROAC H s
CUSTOM CONSTRUCTION 2,30.003F,
POIit".Hi'PATIO 580.00 Sit'
C"lARAOMAR SORT QSFj ler,464,40
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X= C�V$,fd. 0 C'�idd�'Y9.4A'�14.71+.E.d11.i,N
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di 0151WK41 p,
gd�Y8Y.6.N.>:K'tA
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C;C+1 �'I?,tSCr �?fig FOR M-000-410-000 00.41 0-000 5110 50
PUN Cmrcit. IMS 401-000-439-318 $930.4
MWIN .ft ICAL FM 101.000.421, W0 $93.4e^-
0"WMUCAL ITZ 101-000420-000 $381,36
F4StlDtiBi'4 G ME 103.000.419.000 $168.11fl
. , STROUG SIG TION.ir&P, v X% Eke 101-000-241-000 $30.59
ORADWO.AEF 101-000423-000
I.9WBUIPER b.1a1'PACT ITER,
AWf W PUSUC PJAM- REHE7 9.00-255.Ora SKO
01A'.`:t'C AL CONMUCT "tx ON AIM PLAR CHP -1--C
$4,185,05
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$0.00
3'*+ wRJ.3 dF S .'4.C�.1.' KE2.� Dur .� SYCN A'Y
RECEIPT
DATE
BY
jI
.•.lF,rF{
!-0
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE -7
INSPECTOR -
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms &Footings �%Ql/�
Slab Grade !!'�'
_
l_ -�! _
Ducts
Steel
_
771 p�
Return Air
Combustion Air
Roof Deck
_
2�! pj� -r-,
Exhaust Fans
_
O.K. to Wrap
F.A.U.
Framing
7—p—
Compressor
Insulation
����
Vents
I
Fireplace P.L.
Grills
_
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wali Firewall
Exterior Lath
Drywall -Int. lath
0/
Final
— ✓ _ — _
na
Fil
= —,i—
J
POOLQ $PAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
_
Footings 2p(,(':
Main Drain
Bond Beam
/
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Waste Linesj
_
Electric Final
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
_
/Of
Pool Cover
Encapsulation
Gas Piping
Gas Test
/
Appliances
Final
FinalLEI
- -OMMENTS:
—�--�&A/UtilityNotice
(Gas)
_
I
ELECTRICAL. APPROVALS
Temp. Power Pole
_
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
_�f J
Final
WilyNotice (Perm)
Wily1—IMWEI
— _
b'
Certificate, of Occupancy0 0
Tiff 4
Lvcowou��4
C
OF 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: 81-200 LEGENDS WAY
Use classification: SINGLE FAMILY DWELLING Building Permit No.: 0012-287
Occupancy Group: R3 Type of Construction: VN Land Use Zone: RL
Owner of Building: SHLR OF CALIFORNIA, INC. Address:
City, ST, ZIP:
_ By: BILL GORDON
! &-t,.t
Date: NOVEMBER 22, 2002
Building Official
POST IN A CONSPICUOUS PLACE