0301-096 (SFD)LICENSED CONTRACTOR DE CLAR4TION
I'herePy'affirm Under penalty of perjury that'l -am licensed Under provisions of
Chapf ' 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
U�te Signature of _7
OWNER -BUILDER DECLARATION
| hereby affirm under penalty nfperjury that | am exempt from the Contractor's
License Law for the following reason: '
( ) |, as owner ofthe property, ormyemployees with wages astheir sole
compensation, will clothe work, and the structure isnot intended o,offered for
sale <oov.r044.Business aProfessionals Coue>.
( > | as, owner of the property, am exclusively contracting with |monoou
contracto.�s to construct the. project'(Sec. 1044', Business & Professionals
( ), ! am exempt Under Section B&P.C. for this reason
Date —Signature of Owner
WORKER'S COMPENSATION DECLARATION
| hereby affirm under penalty of perjury one of the followingoo|ammono:
<>| have and will maintain acertificate o/consent toself-insure for wmmon;
componsation, as provided for' -by Section 3700 o/ the Labor Code, for the
performance mthe work for which this p&mitivissued. .
1�) l
have and will maiworkers' compensation insurance, as mquir6dby
84�on o7000fthe Labor Code, for the performance of the work for which this
o*//nu|vIssued. wxwo/kem'ovmve/.*auu//|//=u/a//Gnu,../e.&policy .`o.um!
Carrier STATE MID Policy
(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 employany person in any manner so as to become subject to the
workers' compensation laws of Califo-mid, an I d agree that -if Nhould become
subject to the workers' compensation provisions of.Se'c"tion 37doof the Labo'r;
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject anemployer mcriminal penalties and civil fines vvmpmv.vvv...
auumonmmeuna cxoomponoouon.damages aapmvmouxxin00000noroe
ufthe Labor Code, interest and attorney's fees.
IMPORTANT Applicationis hereby made to the Director of Building and Safety �
for permit subject
m �m! o conditions
onpm"ona`anand restrictions o'm mnn on his
application.1.Eaohpomonm m�appn��on-iamade aeach pomona�t
�.0
performed under or . .
a��n�����a��n��i a��� mshall, |�m�
u hold harmless the City of uuQu|ma. its officers, agents and emp/vyaeS. .
3.Any permit issued ooaresult ofthis application becomes null and void |f`^
.
work is not tommeooeu within 180 days, from date of ixov9nvv of such
'pa,mit, or cessation o/work for 18Odays will subject permit to cancellation.
|mortify that | have read this application and state that the above. information iu
correct. I agree to comply with all- City, andState laws relating to the building..construction, and hereby- authorize representative's of this City to enter upon -'-'.':the above-mentioned pro'lie'rty for in'spection purposes..
Sinnature '�_, ate
"BUILDING -PERMIT--
DATE VALUATION to LOT T RACT
JOB SITE
ADDRESS 49--136 Vu C0NQ01trVAMR
APN
0,55451-210- 06 1
OWNER
CONTRACTOR / DESIGNER EN61NEER
(160>T71-194,1 CBLO 299";
USE OF PERMIT
WALIA% PO04 SEA OR'. DRIVEWAY APPROACH. IS% REDUCTION TO
PLAN MIECK PEE 101,000-439.318 $308,1n,
MECHAMUL, FEE MeOQO-421-000 $1361$0
ELEC,TfUCA.L RX
L.130 PRri,41MMS
$0.00
FX11haT FEE'S DUE NOW
a54252IMS
7DATE
FINALE
----_�-~_
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
_
Ducts
Slab Grade
Retum Air
Steel
— 2 - 3
Combustion Air
Roof Deck
_ /—
Exhaust Fans
O.K. to Wrap
_
—
F.A.U.
Framing
Compressor
Insulation
_
VentsPIC
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
LX
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
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
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
_3Heater
Final
Water Piping
Plumbing Top Out
_ _✓
_ —HL
Plumbing Final
Equipment Enclosure
Shower Pans
Sewer Lateral
O.K. for Finish Plaster
Pool Cover
Sewer Connection—Encapsulation
r
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas) —icy
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
Utility Notice (Perm)
COMMENTS:
t
of c
�- - Certificatb,0F0c&qpancy,_z,
G�oF9t , &Safety :Department
.Building
�r u
;This Certificate -is 'issued,: pursuant,to the requirements df Section 109 of the California Building
_
Code,.: certifying that, at the time of =issuance, this• structure was in compliance with 'the
- -ti
-� provisions ` of the Building Code and the -various ordinances of. the, Cityregulating building
construction and/or use.. F �,
.BUILDING ADDRESS:,49=736 VIA_CONQUISTADOR
,
Use°classification: S.F.D._ * '
•
' -,: • .' ; _� ' Building Permit No.:, -0301.096
+` , ! ,
Occupancy,Group: R-3 �` - i ` ' Type of Construction: `-N-V -."Land Use Zone: `R -L.
_`
Owner of,Building:TD. DESERT DEVELOPMENT �';' - y`s�' Address:,�PO 60X`1716 `•
f
City; ST,,ZlI,: LA QUINTA CA. 92253' �
` µ By:`G.'SHOWAL'TER
" ; , r• ' V _ Date: 04/05/04
,; .. -Building Official
- y POST IN A CONSPICUOUS PLACE i '