0112-085 (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
4786$9wf .
Date %• �% Signature of Contractor
ar °' +nid' t •
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).
O 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 6y Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
( ._),_f 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 'J(71r3DEN RAM Policy No. I'M M70111101
(This section need not be completed if the permit valuation is for $100.00 or less).
O I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any manner soyas to become subject to the
workers'. compensation laws of California, and agree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with th .se provisions.
Date ''� _->!1 Applicant—
Warning:
pplicant 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.
1. Each person upon whose behalf this application is made & each peFsonrk
whose request and for whose benefit work is performed under or pursuant to -1
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 City to enter upon
the above-mentioned property for inspection purposes.
L
Si nature (Owner/Anent) Date's c11"'
PERMIT #
BUILDING PERMIT��w
DATE VALUATION �� wr ,i�M LOT TRACT9 1
,..
JOB SITEit
ADDRESS 4");1% 11110. DEL SOT.
APN
OWNER
CONTRACTOR/DESIGNER/EN (NEER
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7'8-S20! PIAS !.A
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.QX TA, C'.A 92,253
LAsQUIR A CA 9-2253
USE OF PERMIT
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RSOOCT1011 FOR N1U>r.'Pti''LZ IS'S 1.F''<NCE Oi';i.AME PLAN TYPE
TRACT V*ItISTRUCTfON Z4$1A, O
RORC.i1IPA.T10 76.0 We
C:iAR,.F 15MCAFiRPORT 629,00 8F
'1937MAX&D Cosr OF C:ONe'�'$MU .0.9
1, 14:61971";N)
C:OOS'#'RUC T TON FEE 103 _00 _41?3_JUCf
PLXH CHECK FEE 101-000.439-:316
9i.Cikfial2dlC.°Fbt:F`k�)� 101^C1b"��Z)�l(ii $79,00
9LACTRtC.AL YUP 101-000.420-000
PLUMO11+ O FEF, $169.50
STRONG MOTION PUE a 1�..1�JID 101.010-2741-000 1 11142V
ORA.DWPEL. 101-090423.000 1� W1.0
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RECEIPT7
DATE ;
BY
D FINyGE� n
INSPECTOR
a
)X
A.•P7�
44
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
-Z
Underground Ducts
Forms 8 Footings
-Z
Ducts
Slab Grade
-/O -
Return Air
Steel
_ j -Z
Combustion Air
Roof Deck
R
Exhaust Fans
O.K. to Wrap
17--2
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-
-
Final — 57
BLOCKWALL APPROVALS
Final
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
-2-
Main Drain
Bond Beam
Z
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
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
Utility Notice (Perm)
COMMENTS:
-
-
Certificate of Occupancy
: City of La Quinta
Building and -Safety Department of ... o
This Certificate issued pursuant to the requirements of Section 109 of the Uniform Building Code,
certifying that, at the time of issuance, this structure was in compfiance with the various ordinances
of the City regulating building construction or use. For the following:
BUILDING, ADDRESS: 44-405 VIA DEL SOL
Use Classification: SINGLE FAMILY DWELLING Bldg. Permit No.: 0112-085
,Occupancy Group: R-3 Type of Construction: VN- Land Use Zone: RL
Owner of Building: CENTURY AMERICAN DEV
Address: 78-520 VIA SEVILLA .
City: LA QUINTA, CA 92253
By: STEVE TRAXEL
Date: 1.1-27-2002
Building Official
POST IN A CONSPICUOUS PLACE
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