0203-040 (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,•
591561
Date �.� Signature of Contractor
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 by Section 3700 of the Labor Code, for the
performance of the work for which this permit is -issued.
• *( ) 1 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'.A"2'3j FUNp Policy No. ` 1615139141
(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 manned so as to becorn ,.subject to the
workers' compensation laws of California; anal agree" that if 1lshould become
subject to the workers• compensation proftions�Se�cfi 700 of the Labor
Code; II shall forthw't, comply with those pt'ovisions:
Date:, z?,fir ✓ 3 / 7Agpplicant 1,1"b'1 AL `.4L i
Warning: Failure to secure Workeis' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000; in
addition to the cost of compensation; damages as provided for in Section 3706.
of the Labor Code, interest and attorney's fees.
IMPORTANTApplication is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application. "c
rr : .
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under -or pursuant to
any permit Issued as a result of this applicaton agrees to, & shall; indemnify.
& hold harmless the City of La Quinta, its officers, agents and employees.-.
2. Any permit Issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such,
permit, or cessation of work for 180 days will, subject permit to cancellation.,
I certify that I have read this application and state that the above. Information is
correct. I agree to comply with all City, and Statedpa vs°relating to the building
construction, and hereby authorize represerifatives�of this City to enter upon
the above-mentioned property for inspection purposes. r •,
Signature (Owner/Agent)R`= ` Date f ? r
BUILDING�PERMIT PERMIT#
dk'�A"� •£t�43 y
DATE VALUATION t�dC3@ip�A. LOT k TRACTJOB SITE
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ADDRESS .3'6�E.�'��C APN �.'�•'.�.,i.8�'^y. '
OWNER CONTRACTOR/DESIGNER/EN (NEER
F. °LII
CA 92780 IrWITIN CA 92780
(?V0508-4440 C.BIPA 4485
USE OF PERMIT
01wa:?,>+wfa vWRI::T 1,x3-
SFD , LOT 118 Pi.A.`M 30..0. PF'1$,MIT DOES NOT INMODF. SLOCK
WAU A KXA.y ITA, OR DR.1VVPVAY .hP-PR0A0ff
TRACT C 3li0R'lFCTION 10114.00 Jig
PORCHIPATIO 275.00 10
WWWWARPORT ' 630.00 SF
1415 ':DINNED COST OF CONSMUCT101
F,V-,R,IVM' TKE RUMMAIN
00140 `�tuc'!'im r -R&
101. W, 0..,4,1r13WMIQ
M3.00
PIAN C.Nf JZ;K KPF'
101-000-439-31 l &
rS'aA& III
P4.841,11A ICAL FZZ
101-000-421-000
8'A UD
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1171.-�34tta �I?.>��ililtA
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PLUMBINOFtE
'101-000-419-000
119,54
cl AWTO ;E
.t31 �t'1Gt1 i af3f3w3
$ C!),it3
DEVELOPER 1MPACT 11"F: -R
$2wrJi}7,00
M11751.70
r am- ( r CO. l:; g•-MyN -AMD
PT .ph7 MMM $4,109.01
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C9YOFLAQUINTA , #
F=WAICEDEIN 2
RECEIPT DATE kr �.}: BY DATE FINALED INSPECTOR
• t. -� �/�":r47.`t= N:,/`.p!_ _�—iso 3 .
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
TINSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
7-7Z 3
Underground Ducts
Forms & Footings
-v
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
.,2-.9 Z_-$ 7
F.A.U.
Framing
?Z
Compressor
Insulation
®- o-• z 57
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
/- j .o s—
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL
APPROVALS
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
_ Z _ a
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
`(o.o7i S]
Encapsulation
Gas Piping
Gas Test
/�� .c) 5-7
Appliances
Final
COMMENTS:
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 r
Utility Notice (Perm) o
- • . rf, - yam- � •
.Building and Safety Department c�MoF�9w
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 following:
BUILDING ADDRESS: '47-600 VIA FLORENCE
Use Classification:' SINGLE FAMILY DWELLING Bldg. Permit No.: 0203-040 `
Occupancy Group: R-3 Type of Construction: VN Land .Use Zone.: RL
Owner of Building: CANADAY & COMPANY Address: 17480 E..17" ST. #106
City: TUSTIN, -CA 92780
By: STEVE TRAXEL
Date: 02-12-2003
Building Official
POST IN A CONSPICUOUS PLACE
M._