0301-064 (SFD)c 'LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9,tcommencing with `Section 7000) of Division 3 of the Business and
F(ofessionals Code, and my License is in full force and effect. -
License # Lic. Class Exp. Date
674077 13 :RIC
/rw'�
Date` Signature of Contracto17
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).
( ,) 1, as owner of. the property, am exclusively contracting with licensed
contractors to .construct the project (Sec. 7044, Business & Professionals
Code). ; '•
O I am exempt under'Section. ' B&P.C., for this reason
bate ` Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm. under penalty of perjury one of the following declarations:
( ) I have and will1maintain 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.
(F) 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`Policy No. Oq:"183�-2003
(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 fha if,l should become
Subject to the workers' compensation provisions of Section137.0C�of the Labor
Code, i shall forthwith comply with those provisions.
Date: �7 7 2 ' 'ml Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawfulland
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. ;t agree to comply with all City, and. State laws relating to the building
construction;.'ano, hereby authorize representatives of this City to enter upon
the, above mentioned property "forr'inspection purposes�'-1
�,� Date
—:'—
�Signature- (Owner/Agent)�...,... !�
BUILDING PERMIT PERMIT"
DATE. VALUATION JW-Zo LOT 9 TRACT ?q g
4 3 c td
ADDRESS �;s= aA OTi rC� rCd �A 4+% " JOB SITE
APN CA9�_210_067
OWNER
CONTRACTOR / DESIGNER / EN (NEER
TD
ro BOX 1716
79 295 Na0-10 L-A QUINTA W.,
LA QLMW' . C'rk 92253
LA C)1111:7TA CA 922,'S3
USE OF PERMIT
X1..3 , WT 9 PT AN DA3. • 109R MIT r)DES' NOT INCL,IJOE HLAXX •5'aAi!.1Z
04 :V, A OR DMEWAY 01I'P}I:O.�+ %. ISS"o'PLAN C:liECK FER,
U 0UC'x`K)N f?011. 6Ai3,€;'1'•DPLY,:I SUAeNC F, OF SAME PIu+R73T TYP?
;,'US'i OM CONSTRUCTION 4.243,00 O
GP,htAO]'d ARPOli. tft,tlB tier
y��g•�. �y.��n�a �7�s j�g,p yh1.F:Y.iAfiJ9A,�I.Sadf
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yi�.t�i•y,, g�Ri3.86E.r 77 Cy. y�Nt�1 R RA
- COAS TRUC"�.Il�' N P ' 101 -0100-41 A3 000 SLIS7d1150
.
PLAN CHECK; FES
MECHANICAL SSS 1011-(004711-wo $146:50
R=ZRICAL P0,11, 10,11 -000-420-400
�rfl�j a a Pay 101m000-419.000 x605.0D
STRONOAIiOT10XPEP�.I VISID 101.000-!AU1!-000 $35.14
c P. 0,1". N0FT, F, :i 01-000-444w.000 W,00
D:VEWI)FIIR IMPACT FSE,
y0 -J00- -45-000 d3wad 4O7t
��Ir 2:70 -000 -4 -45 -000
3Ry11iVF4X P4&4lS `
gUB-�'CyTAL CONS '11'1`DICTION Al�yts��•;;P��yy�.f�lW�hy}i Cp{F4yy��/fi��K
$-552652.05{.
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RECEIPT
DATE
BY
DATE FINALED
INSPECTO
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
S OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set.Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
—/ —
Return Air
Steel
_/ __C/ --vim
Combustion Air
Roof Deck
.3
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
el
Final _ p
Final>
BLOCKWALL A ROVALS
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
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
$ 2
Appliances
Final
Final
Utility Notice (Gas) AS
ELECTRICAL AP ROVALS
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
Utility Notice (Perm) i
COMMENTS:
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�0F.:9Building:&Safety`Departrr,ent
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This Certificate' is 4ssued . pursuant toy the requirements of Section' 109 of `the California Building -
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Code, certifying that, at ;the' time, of issuance,-. this- structure 'Was ,ln. `compliance wit h° -the..:''
•, provisions'`, of . the Building Code ,•arid a'the various •-ordinances . of the City regulating<building "
construction and/or use:
BUILDING ADDRESS: �49.659,CONQUISTADOR
+ Use classification SINGLE FAMILY -DWELLING ING ,1. �r_ �� °� '�; Building='Permit°No.. ' 0301=064'
J, ,
Occupancy Group: R3 , � � 'y'-•� Type ofConstruction 'VN' `.� •� ,. Land;Use Zone:. RL
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a'Owner�of'-Building TD"DESERT DEVELOPMENT Address: PO BOX 1716 ;
City;'ST, ZIP:7 LA•QUINTA' GA 92253 .
.
VBy.
•GARY.SHOWALTER;
Dater ..12/16/2003
k: Building Official A.
POST IN A CONSPICUOUS PLACE
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