0301-084 (SFD)LICENSED CONTRACTOR DECLARATION
Nereby 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
6174074 B BIC ' � 7131103
Date'^ f� 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 is issued. My workers' compensation insurance carrier & policy no. are:.
Carrier I`1AMIRM-015 - Policy No. 046.73a�1`4"I �.
(This section need not be completed if the permit valuation is for $100.00 or less).
I(.). 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 fhat if I should become
subject to the workers'' compensation. provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Applicant -" 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' fo'rth?on his'
application. c
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 Ci fo enter upon
the above-mentioned property, for inspection purposes.
Signature (Owner/Agent)' - s e Date
BUILDING PERMIT PERMIT#
DATE VALUATION $2,$2.1 a ()0 LOT 79 TRACT 29283
KrJOB
SITE
ADDRESS 4�a48't)J (_'��il^i��, �iT�A.i�DOR
APN .649-210-M7
OWNER
CONTRACTOR / DESIGNER / EN (NEER
PO BOX: Rai 6
LA QiF1krrp: , CA 9.22,53
R:AQiJ'lmw CA !32253
(760YM-15941 CKA 2996
USE OF PERMIT
S1al� - L,OT 29 PLAIN 11 11+.. PERMIT POES NOT 1'tsC1.,t 02 S1a€JCK
WALLS, PO -04 BRA OR DRIVEWAY APPROUNT 750A Rf MUCTION TO
1'idr?H tiblFXX FFM DUEZ TO 16ULTIPLF$Z:3i7A14CE OF $dvE PL1MY6PE
CUST. M OC1N0 TR3,UC'i'ION V48100 IS
POACWPATIO 5110,00 wp
GARAGMARPORT 60100 SP
mm,ta.tlevit'�Tt I've. 101.000418.000 St,29U,00
PLA*N C% ErNk IME $s"MX3
141J CHANICALYEZ 101.000.4.2-M) %149,50
E1. K.fPl(:/tLYFUI 8133-ttofl-; a>Caf)L} $115.04
PRi(73t BY190 PER 101.-0041 M00 9707,25
TRONO M07 IMI A'L'T? , ra.f10 10 -000 -241 -NO $29.21
fs.flOf ATtf t�� 101'•G�00g2a; ^at1Y� SU.t1f1
L9WZL%1PER 1$! PACT FEE, sv,05.00
. lef IN i U014110 R LAC - RUSIE 270-WJ-445.000 S.,. Ms 77
'LJLvA`�9'i'i�.�pC3tJ`!'tCi;'1SC3A1,Til ii'T;1!,14 GT�;rC1?.
$4,164.50
:. LP -M pRa—PAID FUM
$0.00
!ll
c.rf L c� �„St� ��
pita► . f:
M,gty,OE,r,EE,i.
RECEIPT DATE
BY ___TDA
TE FINALED
%/—
INSPECTO
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ay
Ducts
Slab Grade
— —
Return Air i
SteelAl—
3 _
Combustion Air ±
Roof Deck
_
Exhaust Fans
O.K. to Wrap
_��.
F.A.U. 00 4
Framing
_�Q- 3
Compressor
Insulation
_ �- 3
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines -
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
_
D
Final -
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
I
Gas Piping
PLUMBING APPROVALS
Gas Test —
Electric Final
_
Waste Lines e
— Qr s5
Heater Final
Water Piping_�
Plumbing Top Out
c3
Plumbing Final
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
z
Pool Cover
Sewer Connection
-
Encapsulation
Gas Piping
Gas Test
'Appliances
Final
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 Power
Final N
Utility Notice (Perm) / / -
COMMENTS:
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.Certificate
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oF:9�'��f .- Buildings & . S06, .D Department
This Certificate is issued pursuant to the requirements of Section `109; of the California -Building
Code,'; certifying .that, °at -the ,:Ytime of issuance,�.�this structure- was Jn compliance with the'
provisions.,of -tlieBuildingZode and . the. ,ordinances of the': City regulating: -building` "
,
use:
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:construction , y
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• AD
ILDING A DRESS: •49=448 VIAti CONQULSTADOR_ `
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l7 .R. "'ate ti.+ "r
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a 301-084
ctionSINGEFAMILDWELUse-elassifiBuildin :Permit.No '0
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Occupancy:Group. _R 3'' �� Type of Construction, V -N Land Use Zone: -C
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�'Owner of Building: 3D DESERT. DEVELOPMENT Address PO BOX 1716
City; ST, ZIP LA QUINTA' CA 92253
a' By GARY SHOWALTER •. '.
Date 11/07/2003
:'
,-Building'Offici
'
` ', w _ POST INA CONSPICUOUS PLACE `