0301-091 (SFD)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
7/3-110.1
Date �� -ir Signature of Contractor "' f
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.
Y) 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 . ;r.rATE 17 ,PMD Policy No. D464/338 -a00)
(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,°tha if I should become
Subject to the workers' compensation provisions of`Section 3700 of the Labor
Code, I shall forthwith comply with those provisions. I
,,Date:,
.'l `i Applicant
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. t- ;
1. Each person upon whose behalf this application•is made & each Person -at
whose request and4or whose benefit work is performed under or pursuant 4o
any permit issuedas a result of this applicaton agrees to, & shall, W emraify
& 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 a9d state that the above inforrriation�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 propertt/y for inspection.purposes. c
1
;Signature�(.O.wn WAgent) - :Date` Z_'i"'A'
BUILDING PERMIT PERM T#
DATE VALUATION LOT TRACT -
JOB SITE
ADDRESS�� %;F+�►��
APN
f�i�'t�
OWNER
CONTRACTOR/DESIGNER[/EN 1NEER�y
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QUINA CA 92253
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(760)?71,1.941 I %JP 2996
USE OF PERMIT
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SYD r LOT X. PLAN 'MR. FEWIT DOM, 0T VC 1,UD2 B.LOCK
STAB L,% 1-1004 PAM PLAN
CHECK FrY. DUt '3'O MULTIPLE ISSU NC2. OF SAME PIAN TYPE
CUrsOM COINSTRUCTION. 4,245,000F
i ORCCW/PATIO 532.00 SN,
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CaNgTRUCTION PT.R 101-000418.000 wj?.I.50
MAN C149CY.; IF= 1014)00,439-318
M&CHA101tAL,ME 101.000-421+0100
EJAZT.R10AIJ FEE 101-000-420-000 UAVW,
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xr-RON. a I ADI` JQM ISE o Rif ? Q1 M600-241-000
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':ART 1N PUBLIC PL/:AW11-1EIL`,13I1 Z70-000.445.000 ��e?�°4►
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A .. - FINAN. E VIEP1a -
RECEIPT
DATEr3rca
BY 'LL",,✓�r
DATE FINALED
INSPECT
INSPECTIOhALCORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
M BUILDING
APPROVALS—
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms &FootingsDucts
Slab Grade
�$— —� _�
Return Air
Steel
_/
Combustion Air
Roof Deck
—
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
�— / „3
Compressor
Insulation
— — 3
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
_ .. ��/ �W.,
Final
i
Final
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
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
��3
Heater Final
Water Piping
ally�)
Plumbing Final
Plumbing Top Out/��
_�
`-�
Equipment Enclosure
Shower Pans
z
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
3
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas) T
ELECTRICAL APPROVALS
Temp. Power Pole `
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fb(tures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) �.
COMMENTS:
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Certificate is: issued pursuant to the' requirements :of� Section • 109 of `the California Building
-Th
,.eertifj ing 3 ;#h it;r, a't `the time of issuance; ;this -structure_' was in z compliance :with; the
rov�sionsn of.: the"°Buildin Code ,-,and, the., -various. -,ordinances+ of the =City regulating` building --
Con itructiom fid/orruse gf. v .. f, y
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8'ulbiNG ADDRESS: 49-6I N- 1k CONQUISTADOR �y=
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Use' classification S:F.D - ", ,. "r ;,� � BuildingRermlt'No.:.0301-091
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Occupancy Group: R 3.- �, `Type of�Construction V -N Land Use Zone ' R -L
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� ,-Owner 6
TD DESERT. DEVELOPMENT '� i Address:�PO 60X,17177
of�l3uildin
w� :. • h, =r �- "° City, ST, ZIP. LAQUINTA: CA `92253 ;.
BY: G. SHOWALTER
_ u Date..04/07/04.x,
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',Bumg Official
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ti _ .POST IRA CONSPICUOUS .-PLACE