0112-080 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
iapter 9 (commencing with Section 7000) of Division 3. of the Business and
Professionals Code, and my License is in full *force and effect:
License # Lip. Class Exp. Date
tdrt
Datet--Signature of Contracto,_r
OWNER -BUILDER DECLARATION
I he"reby affirm . under penalty of perjury that 1. am exempt from the Goiniractor's
License Law for the following reason:
( ) 1, as owner of the property, or -my employees.with wages as their sole
compensation, will do the work, and the structure isnot not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
( - ) 1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044,. Business & Professionals
Code). , ', I .
I am exempt underZection B&P.C. for this reason
Date §ignature os Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty ofperjury one of the following declarations:.
Lhave and will maintain a certificate of consent to self -insure for workers'
compensation, as prov , ided 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 LaborCode, .for the performance of the, work for Which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
"' Policy No.
"Carrier•GQLDW RACUS NWO 34761401 -
(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,
[,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 prpyip . ns
Date - I 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 uponswhose 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 uR
& 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 Js 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
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
ra 63 911
'08 SITE APN
ADDRESS '04
78 10
JOWNER
CONTRACTOR / DESIGNER ENGINEER,
CEIMIRY A�MJW 3YEN1WPWN,,T1
T%-52,0 V14 ', 5UMM a A
CP. 92253
USE OF PERMIT
CENWOZY ANWICAN 1YEW*:WP3YfMT,,
92233
LP4 Q7-WYA ;,,CA 9
(%0)564--5612 cnilh. zm ko
31FO -OT 63, PL.AW WHaWIT .00ZS)X)`r JNC LUD9 SIXICK, 'WA1,14
P0,01.Li 91% ORDRIVIM1.AY A.PPf-',0ACH. '75% PLAR CHEC= YZE
RIM)OCTIO."N FOR MULTIP.LF, ISSUANGEOF SAME PLAW TYPE.
TRACT C'014STRUTC1'rJCN 5F
PORICHIPATIO 61. (W SIP
0ARAMMARPORT 682,00 3rf
E.FMAUD COSI' 010 CONY11IM-MON
PR%M.T M11", HUMM MY
CONS TRUCTION)"Sly,
101-000-418-000
$954,50
WMICHANICAL FEE
50
F=
101-000-420-00
$119,12
PLUMBINell FEE
101-000-119-000
$17oo
STR(YNO DA(Y.F.10W IFF E. - R&MID
101-000-241 OZ
$.3,8,95
0MADINO ME
N0,00
DrVY-LOPEP. IMPACT YE -10
$2,0,07.00
SUB TOTAL CONUMD in 109 AND PLAT CWWK
Lras PRE-PATA) Pm
".NOW
AL IMMU XS IYU R YL
MAR O.
7 20
construction, and hereby authorize representatives of this City to enter
the above-mentioned property fqr, inspection purposes!
RECEIP
.§ig,pature, (QwnEr/Agent)-!::2gbate.)'
r"7
BY DATE FINALED INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
_ _
'-�
Underground Ducts
Ducts
Slab Grade
Return Air
Steel?j
_
-�_�-
Combustion Air
Roof Deck Sc� aAur�
_
3� �(�
Exhaust Fans
O.K. to Wrap
F.A:U.
_51
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 1
7 /«
Final !p� s /dL 6�
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
Waste Lines�j'/�
-¢- Z
Electric Final
Heater Final
Water Piping
_
Plumbing Final
Plumbing Top Out
v
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
gj .� aJ
Encapsulation
Gas Piping
Gas Test
AP_�
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
O Z
Utility Notice (Perm)
�?�
Cerfifimr-cateof,O'c,cupanc-y:
Cit of La Quanta:
Buflding and Safety Department �oF
This Certificate issued pursuant to the requirements of Section 109 of the Uniform Bui/ding 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: 78-405 VIA SEVILLA
Use Classification: SINGLE FAMILY DWELLING Bldg. Permit No.: 0112-080
Occupancy.Group: R-3 Type of Construction: VN Land Use Zone: RL
Owner of ,Building: CENTURY AMERICAN DEVELOPMENT Address: 78-520 VIA SEVILLA
City: LA QUINTA', CA 92253
By: STEVE TRAXEL
Date: 10-15-2002
Building Official
POST IN A CONSPICUOUS PLACE