0301-087 (SFD)' `LICENSED CONTRACTOR DECLARATION
Al
I hereby 6ffirm..under penalty of perjury that I am licensed under provisions of
with "="o.'"='=Division ^othe �Business and
^Pm�uviona|oow�uo.anu�uvonooiuin,un�nmand �eo�
uvnaew umm �m
o�o��oo
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61404 BMC '13 103
Date 'Signature of.Contracfor— -
OWNER -BUILDER DECLARATION
|hembyaffirm under ponokycxpe�u��oo|omoxem��om�eCon�uom/o
uoe�mm
oe�ow,albnreason: '
( > |.���,�mo����mmymn���w���u�o�,��
compensation, wiUdothe wm�.and the �m�vmionmimondodo,offered for
s�o(Gnc.7o44.Business up�v�oxiona|oCvuo).
( ) .|, as owner of the bm am o^n|uoivo|y contracting with licensedcontractors 'm construct the project (Sec. 7044, Business &P��ouiono|s
Codo)'` '�
()`|ome�m�un�,G�n��.oupC.�rm��a�n_______
Date mcxOwner
'
WORKER'S COMPENSATION DECLARATION
| ho�by.a�nnunder ponakym perjury one of mo following declarations:( > |x�aa�vwnm�nmnooeu�a��o�o�t�o��om�,wo�o�
compansoxion, as p�v�ed � Section oroo of the LaborCode, for the
po�onna�eo/the wm�for which this `
��L,�h�e*ndvwn m�m��compensation �
n inovnceamequimdby
Section 3700 of the �
txo Labor Code, ,o performance of the work for which this
pormit is issued. my workers' compensation insurance carrier & policyno. are:.
Cam8lB
Carrier 8%���N� . Policy No. 040M)8-200) '
�
(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
yyorkers' compensation laws of California, and agree that if I should become
subject to the!workers' compensation provisions of Sdcfion)3700 of the Labor
Code, I shall forttQth comply with those provisions.
Date` - Applicant
Warning: Failure to secure Workers' Compensation coverage is UnIal arid
shall subject an employer to criminal penalties and civil fines up to $100,000, in
a I ddition to the cost of compensation, damages as provided for in Section 3706
o f 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 36n his.
1. Each person upon whose behalf this application is made & each pbrSon'at
whose request and for whose benefit work is performed under oF,pdrsbant t
any permit issued as a result of this applicaton agrees to, & shall, ind
emnI
& hold harmless the City of La. Quinta, its officers, agents and er ployees
2.
It of this application becomes null Ind void I Any permit issued as a resu and void Iii
work is not commenced within 180 days from date of issuance of S�c
permit, or cessation of work for 180 days will subject permit to cancellatio
I certify that I have read this application and state that the above information
correct. 1, agree to comply with all City, and State laws relating to the buildinL
construction, and hereby authorize representatives of this City to, 6nter -upon
the above-mentioned property fo ti purposes.
` '^
BUILDING PERMIT
DATE VALUATION LOT TRACT
:43 81
ADDRESS
1A OYINTA CIA 92.133
I.A q,=A CA 92253
USE OF PERMIT
CUSTOM CONOTRUCTION %348,00 sp
0ARAGWARPORIT BF
(41 _ftRVC1VCiT4,FL P 101 -.000-4 10-000 $112801140
PLAN CHZCK W- E
SIXMRICAL MR $40.04
101-000,,4119-000 $202,23
Aik'I"1114PUSLIC PLACES -.09% 270-000-44,50-N)
am
=3_�aml
JAN 2 -2003 1 LA
CITY QF LA OijijoyA
-�--.- `----.=_ -
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
4/ — ;o - 3
Ducts
Slab Grade
3 - g
Return Air
Steel
_ _
Combustion Air
Roof Deck
6- _ - S
Exhaust Fans
O.K. to Wrap
Framing
_ 3 S
F.A.U.
Compressor
A -
Insulation
- - c3 _
Vents
v
Fireplace P.L.
Grills
Fireplace T.O.
_ _
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
—/ 7-
Final
I
Final
_
POOLS - SPAS
BLOCKWALL APPROVALS
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
Gas Test
Electric Final
Waste Lines
- -
Heater Final
Water Piping
_ _
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:
Final
Utility Notice
99
�'v 1�
(Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
7-1�
Low Voltage Wiring
-
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
Z 7—
Q1
d
I
'Certificate OW Occupanc
y
0,
0F n
Building & Safet Departme I
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 andlor use.
BUILDING ADDRESS: 49-520 VIA CONQUISTADOR
Use classification: S.F.D.-Building Permit No.: 0301-087
Occupancy Group: R-3 Type of Construction: NL-VLand Use Zone: R -L
Owner of B,uilding: TQ DESERT DEVELOPMENT Address: P.0.1130X 1716
City, $T, ZIP: LA QUINTA 'CA 92253
By: G SHOWALTER
Date: 01/20/04
Building Official
POST IN A CONSPICUOUS PLACE