0012-288 (SFD)LICENSED CONTRACTOR DECLARATION
1 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.
L`1Sense # Lic. Class '`., Exp. Date
i trn x� r
Signature of Contractopr„-...-
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
Ihereby,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
pertormance of the work for which this permit is issued.
11/1 ;(.+�)'` 1 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.
(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,l should become
subject to the workers' compensation provisions of Section,3700 of the Labor
Code, I shall forthwith comply wit(h(AIhosepryprowslon\s
Date:,! i �
�• . /.-<'.�+!' RJ M6.L M ..J C dF `N..^ ..M. ��✓:�.•wn..y
V!P' .✓J'
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 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
L Signature (Owner/Agentj'% --te r i'�"- -mate 42_ale�'Ir�v
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
S278,248.90 f713 26;R,38-- I
JOB SITE
ADDRESS
APN
.OWNER
CONTRACTOR /DESIGNER / EN INFER
MILR, 011, e
1 MILY I413NM. WC,
184,143POU RRA(S CA 92660
3? 'dDii OR f BEACH CA 926603
(949)019.4915 5337
USE OF PERMIT
S. 011., FKN= `TWJA1 ,'q
SPINI)W4 RC. 14T P93WIT DOES NOT 114C:.i!.C7M <
CUSTOM MR11TRUCTION 3,267100 sr.
PORC:FtrSPATl.C3 760.08 SF
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CONSfiRUt'`TIONlr1' 101.000.418.00- n,260,00
PLIAN CHWX FRE 101-000-439-M W,032.82
Mp�E�,��"�tsYrA�,WiC'°ALY.4X 3011••C�t10-42l•tCI0
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ART M MIX .PLAM - ItTMIC 701.OW-255-000 $19162
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OXYD-71"6: AL C'C."sk ►1' A C.°1.10N AND Pi„,A)ST CHECK
'34j,939.76
MEW PRE -PAID MYMS
$0,00
RECEIPTDAT, E < j BYJ DATE N LE INSP
C ,
S /J
INSPECTION RECORD
L. OPERATION
DATE
INSPECTOR .
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms &Footings�� /�/ _
Slab Grade !/ 0ReturnAir
Steel �
Underground Ducts
Ducts
Combustion Air
Roof Deck
�� D/�S_MV 67- 7-,
Exhaust Fans
O.K. to Wrap
Framing
Insulation
G 0('
_U (
/I�p
F.A.U.
Compressor
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath l
Drywall - Int. Lath
Final
BLOCKWALL"APPROVALS
Final 3
POOLS -SPAS
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
Waste Lines /8/D�!
Water Piping
Gas Test
Electric Final
Heater Final
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
_
Pool Cover
Sewer Connection
�,�
Encapsulation
Gas Piping
Gas Test
_
Appliances
Final
COMMENTS:
i�� Awkvwv.
(�
/::p
Final
Utility Notice (Gas)
ELECTRICAL APPROV LS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures w
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) (�S%0
6
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 ADDRESS: 81-210 LEGENDS WAY
Use Classification: SINGLE FAMILY DWELLING Bldg. Permit No.: 0012-288
Occupancy Group: R-3 Type of Construction: VN Land Use Zone: RL
Owner of Building: SLHR OF CALIFORNIA INC Address: 23 CORPORATE PLAZA #245
City: NEWPORT BEACH, CA 92660
By: DANIEL P. CRAWFORD JR.
Date: 4/25/03
Building Official
POST IN A CONSPICUOUS PLACE