0203-045 (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
1 Am
Datel_1'. •� qS�nature of Contractor
. —7---7
g
OWNER -BUILDER
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).
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 by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
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 0'WE i<UND Policy No. 160391.191
(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 pat'J,AI should become
subject to, the workers' compensation pr6vlsienleof Sze tion 3500 of the Labor
Code, I shall forthwi i comply with those provlslgnsr �' d
mate: /I e...`Jr/`'IApplicant ,'�`.''�r1_y>��r•''.;�
Warning: Failure to secure Workers'ZCompensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to. $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706.
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his a
application.
1. Each person upon whose behalf this application -is made & each person,at
whose request and for whose benefit work is performed under or pursuant to.
any permit issued as a'result of this applicaton agrees to, & shall, Indemnify
& hold harmless the City of La Quinta, its off iceis •agents and employee's 3
2. Any permit issued as a result of this application becomes null and void If
work is not commenced within.180 days from date of issuance of such,
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that l have read this application and state that the above information is
correct. I agree to comply with all City, and Stai�law� I h b 'Id'
construction, and hereby authorize representative�o
the above-mentioned property forrinspeetion p6rp'oses
(Owner/Agent)
re at ng to t e ul rng
this ,City to enter upon
Date6,
BUILDING PERMIT. PERMT#
DATE VALUATION ��LOT TRACT !
�i�rk�Ea'�.'a'1C3 ESC, '-
,•�
JOB SITE
ADDRESS ei`d^eJ:iiF {3:��PICT��
APN
643
OWNER
CONTRACTORDESIGNER EN I(NEER
vlpAgrypATrrlOt#
6ATprA 4% CiYEINy
CA 92790
1110RDW CA. 9,217 80
(714)508-4440 P`I'3'1.6 448
USE OF PERMIT
31-D - LOT T f 26 is 1, 4Jv WAR. PERMIT 0=1410T ANCLUD , V$L,C1=
WAJ,44 P004 513,E OI$ olvv wAy APPROACH
f
TRACT C:ONSTRIUCTION, ?.42100 SP
'
PO CI'1it? A> €`ICS x19.00 K?
CA R.'apiCArillla'RT -00.00 Sl''
11PIr FIFX MOWN
C?OFIMUC:T ION I L� 101.000.4184k-10 580.50
VILA CF1ZC_C,PT,
MECHANICAL $51199
$ itlifi:`f1a7C.R YT3? 101-000420-000
Pill)MB 1140 .M.?z 141 •i3tf�i�i �-d(k0 $a. a� `i."+
STRCENO 1; O TION PEP, R.ESID .101-000-W-000
ORADING FEE 101 -000-423400 VON
IWAg;I':3:, prm WNW? FEE
f.
w'
J til fir 3 C f a i:C� I�� J,3 G C C' Awl.) EO3:.AW 01 MCK
A' ». LESS YRE-PAM''+ rS
$0.00
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-pip
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.01.9l.dgJC'd76�Y.S6.A �,iFPUi�a4,7 +J'�ea;+e NO
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$3y( A•fs6r.3+
Y OF L.p►(1U1M7�+
DEPTy '
RECEIPT'
DATE it yy x+,;
..•jam/'i7 �
BY; *, %
+
DTE FIN9GED
�. Yao
INSPECTOR �.
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7
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-
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
2
Underground Ducts
Forms & Footings
Ducts
Slab Grade
3 —a
Return Air
Steel
Combustion Air
Roof Deck
— Q —
Exhaust Fans
O.K. to Wrap
(p . . O
F.A.U.
Framing
gyp.( oZ
Compressor
Insulation
- 7
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
• yL�t
Drywall - Int. Lath
p - o y S7
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
�
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
!(p.py 57
Encapsulation
Gas Piping
Gas Test
Appliances
� •O 5
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final •O
Utility Notice (Perm) /��
COMMENTS:
no=
Certificate of Occupancy a -
City oj La wumial
Building and; Safety Department, OF'
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 compliance* with the various ordinances
of the City regulating building construction or use. For the folio -wing:
BUILDING ADDRESS: 47-350 VIA FLORENCE
Use Classification: SINGLE FAMILY DWELLING Bldg. Permit No.: 0203-045
Occupancy Group: - R-3 Type of Construction: VN Land Use Zone: RL
Owner of Building: CANADAY & COMPANY Address: 17480 E. 17" ST. #116
Building Official
City: TUSTIN, CA 92780
By: STEVE TRAXEL ,
Date 02-19-2003
POST IN A CONSPICUOUS PLACE
00011R