0112-082 (SFD)LICENSED CONTRACTOR DECLARATION
l �tereby 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 elffect.
License # Lic. Class * Exp. Date ps
Date<t Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty.of perjury that,l am exempt from the Contractor's
License Law for the following reason:, a,
( ) 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,.Busines"s &.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.
. I have and will maintain workers' compensation insurance, as required by
Section 3700 of the Laboi Code, for the performance of the work for which this
permit is issued. My workers' compensation insurance.carrier & policy no. are:
CarrierPolicy No. t
GOLDEN EA�, 0111tF'bJ� a�lt�fiiAO:l
(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 that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code bshall forthwith comply with those,j7f`ov sio �s
Date-" ✓ . .6"f I ::.Applicant -• °
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject:art employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth Qn, his
application.
N
1. Each personupon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to �r
any permit issued as a result of this applicaton agrees to, & shall,.indemnify
& holdafiarmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance, of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this, application and state that the. above information is
correct. I agree to comply with all City, and State laws.relating to the building
Construction, and hereby authorize representatives .o f this City to enter upon
the above-mentioned property.to5 inspection purposes.
r
Signature (Owner/Agent) �-� Date~~ .
.,t.
BUILDING PERMIT PERMIT #U12
DATE VALUATION LOT 7�$s'� TRACT
�Y� ryry ro y
2 L P i' A •• 6
JOB SITE
APN
ADDRESS '75-400 VIS.'SYMI it
OWNER
CONTRACTOR / DESIGNER / EN (NEER
{.`'IiNTY1'it'-f, . AN02,7 f;Gl N D71rVX---:L0Ykd1Murr, Myj
Zlll CE 'a L3IZ3P.' A4 E ,kCIC M TAR''6ELOPMrm1, coz
7$,,120 VIA, tREVILLA
7 8-5 20 "AA DUVRIA
1A.OUMA. a& �-. 922.53
IAQW1 ,I.A CA S12253
(760)564=5612 CM -9 54VI
_
USE OF PERMIT
Matz, AWi:Y DVO TING
STeD ¢ 1.41T a;, .PLAa 3CP, MMIT-00M. rtf0T .(NMUDE RUXX
WA.LM POf;;,4,8PA, OR DRIB#'EWAY.chD?,PRO.A.01., 'fta VIA
A7.013C` 1013 POR i+ftUi.M4 LE =UA:NW9 OF 'SAME T"LAH TYPE
TRACT Cc71` S RIUMON or
_
:pp��>g�
�PttOpp�aC���dggP[[.��,,LL'iyyO�yy��r/�c��+ iag6,71,0.0pp
1-�RRPSV',f.'ad�nul.Si.1 OR X702100 8F
.��YEMryryTED
.qrF cot MdRFlAn
7+a
yWyR
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MIf
CONSa'II CTION FEV, 101-000A 18-000 %91M15D
PLKiq CHECK FEE 101-000-439-318 x198.06
MEC WCAL FRE 101.000.421.000 $85,50
ME I C31.0t�0.4�0-000 �.1`7�. I l
)r1LUMBINO FU 101.000.419-00 9 x17-4.50
u'!'4tO;N15 V101111CY.m MY, 101-000-241-1300 $16.93
01 A.Dt M31 PER 101 -?00.4-23.000 120.09
DZVELT)PER IWACT FE -B -
ry.
l •
„5 -'tufo I ,Z"�UCIV1:O1`TA PLAN S",IMIrCY.
MAR 0 T2002
y�Kms' pp
RECEIPT }r?.
DATE
3
B,y .
y �)
DATE FINA D
q
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
TINSPECTOR
BUILDING
Set Backs
Forms & Footings
Slab Grade
APPROVALS
Z?- �% Z
—L
MECHANICAL APPROVALS
Underground Ducts
Ducts _
Return Air �Z
Steel—
Roof Deck
— Z
..(,�
Combustion Air
Exhaust Fans
O.K. to Wrap
�ZG �pZ _
F.A.U.
Framing
Compressor
Insulation
_
/JJ _fJ Z
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
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 I
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines (?'
,�_/¢ — y
Heater Final
Water Piping��
Plumbing Top Out
Plumbing Final
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
�/� _
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
a
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)
i
,Certificate to of Occupancy-
C.it o f L a uin ta,
Q_
oo IK 1W
Building abd. 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.regu/ating building construction or use. For the following: _
:BUILDING ADDRESS:. 78-400 VIA SEVILLA
.Use Classification: SINGLE FAMILY DWELLING ' Bldg.'. Permit No.: ' 0112-082'
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: • ' 11-01-2002
4 Building Official
• POST 'IN A CONSPICUOUS PLACE