0307-103 (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. E
License # Lic. Class Exp. Date
13 Mc
Date i�^ ' ' 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 isnot 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 `1
( ) 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. M workers' compensation insurance carrier & policy, no. are:
Carrier Gti A'r iSYil ii) �' Policy No. 11§�}O�i92 Df
(This section need not be completed if the permit valuation is for $100.00 or less).
( )
1 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 that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I•shall forthwith comply with those provisions.
Date: '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.
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 State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes. t
6
Signature (Owner/Agent) tt e Date..s
BUILDING PERMIT. PERMITt-:
DATE -,-,VALUATION y�+�� � '7�ti�, {j LOT % TRACT iFr y
JOB SITS D � r:
APNADDRES
OWNER
CONTRACTOR / DESIGNER / EN (NEER
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PALMD�'aNERT Cel. 9.7211
PAUMT�RSER17 CA 92260
(760)772*8274 CTALIf 1137
USE OF PERMIT
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CYRECK .QF, DUB: TO Mt11..I'tp>iX ISSU AVCF: aF SAR P .AH M, 13
Mr, OM C0H3TY'WC.'F 1C.r•'t' 4$19,00 sw
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MOW"i1f'li"'E su�ILRY
C'VAt�'1'!rr`.'JC'�I�i?eY.Ir1?t: 3E,1;1.,4U4.$!1£i>t?4J1] $1,13',90
YT,. N CHICK: PEE,
MECTIAN1CAL%SF 101-000,421-000 $1"1 00
I �,r,TRIC .i. 17,911? $147,25
L.tli�9rs �IC1i `�". 0. 000-4191.000 25
STRONG LIC -71014 "0 `- ttWD 1 C1-tkfi 441-000 $h9.94
MAD r1q. 0 VE 1014,10423-000
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ART 1N PUBLIC III.AC -31 R.w��U 270-:0Q i-44*"000
TQ',ICAL F]KHb. i�:DDE HOW
101
RECEIPT
DATE ryry _
BYDA
E
INAL
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs A,
Underground Ducts
Forms 8 Footings
Slab Grade
Ducts
Return Air
Steel
ombustion Air
Roof Deck i
OX to Wrap
au st Fans
F.A.U. hj
Framing
_
jr Compressor
Insulation
Fireplace P.L.
Vents
Grills
Fireplace T.O.
Fans &Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
i
Final
BLOCKWALL APPROVALS
Final I—
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 PP OVALS
,,..I /_ , /
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
FinalJA A ge._
Utility Notice (Gas) Or
ELECTRIINAL PPROVA
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels /
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) 91- �, 4 oea
COMMENTS:
. .
-<
v. - ( ly
1-1
rt�ficate of� 0ccupa n.cCe, Y
�, 9 - , Bu
ild►ng,&,SafetkDe'parton
OF ;
This 'Certificate issued pursuant to� the requirements of Section, 109 of the California Building.
Code,' certifying, 4hat, at', the 'time 'of, issuance, this structure' was in compliance with the
provisions .of 'the' -Building- Code and. the--various_-.ordinances of._the City regulating build►ngF
construction and/or use,
. Y
'BUILDING. ADDRESS: 80=789 VIA SAVONA.
N . = Building,Permit No.: 0307-163
Use classification: SINGLE .FAMILY DWELLING,� f
_ r
r R.3 s Type of.Construction� VN - = b Land Use Zone: ;RL -
Occupancy Group:
r
Owner of $wilding: SEDONA HOMES Address 7.7-564 COUNTRY CLUB DR.
:City ST, ZIP: PALM DESERT, CA -.
By; BILL GORDON
Date .February 19, 2004 i
Building Official
OUS PLACE
POST IN CONSPICU