0112-067 (SFD).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 CC1.I}10 gf�Y•.S? Policy No.dSJVtw7(32It1!
(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 wlers' compensation provisions of Section 3700 of the Labor
j Code, Iall f,pehwith comply with thosg rovisions�
Date:_ Applicant �,.
Warning: Failure to secure Workers' Compensation coverage is unlawful and
—shall. subject an employer to criminal penalties and ;ivil 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 3 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..l,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 �!f
V',.,..Signature* (Owner/Agent) • ,',''' Date/
' r
BUILDING PERMIT PERMIT#
LICENSED CONTRACTOR DECLARATION
/* S169,48550 25 23971-1
I hereby affirm under penalty 'of perjury that�l.am licensed under provisions of
V)
I—
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
04 W
Professionals Code, and my License is in full force and effect.
O =) ch
License # xa' ^•�'� Lic. Class Exp. Date
ti LLI r`
478689 13 ai V02
Z I`
Date + � �*! Signature of Contractor
C:)
C0.
F- C:)
i
r-
OWNER -BUILDER DECLARATION
W UJ
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U)
License Law for the following reason:
Z_
( ) 1,. as owner of the property, or my employees with wagesas their sole
compensation, will do the work, and'the structure is not intend'e`d 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
109,485,24)
Code).
co
:L
O. I am exempt under Section B&P.C. for this reason
N
O N
Date Signature of Owner
0
W1'ii HCAL, i+ M 1101-000,421-000 "5.50
U Q
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 CC1.I}10 gf�Y•.S? Policy No.dSJVtw7(32It1!
(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 wlers' compensation provisions of Section 3700 of the Labor
j Code, Iall f,pehwith comply with thosg rovisions�
Date:_ Applicant �,.
Warning: Failure to secure Workers' Compensation coverage is unlawful and
—shall. subject an employer to criminal penalties and ;ivil 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 3 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..l,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 �!f
V',.,..Signature* (Owner/Agent) • ,',''' Date/
' r
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 0.11.2-067 TRACT
/* S169,48550 25 23971-1
JOB SITE
APN
ADDRESS
7&430 VIA AW"A
OWNER
CONTRACTOR / DESIGNER / EN (NEER
it i'"NTUR Y AN tKR1CA9.0. E �'. 0PMWf, "�'`C�+.
M (X,)TCMY rAMMCAN-DE�f',�:C.0 PILEW, COT
LAQ 1 "'1A S..A 92233
LAQ4.TD4,TA CA 922*3
(760)5M 5612 CM1.4 5.487
USE OF PERMIT
;Im < 1'al' z.) Pf,,A14 Mk- P.ErRIMIT DOES AYi)`i' TNCk,t30.E BLOCK
WALIAP004 VA, Oil DRIVERWAYINTROA(M.
-r
TRACT C014Si`RUC"1ION Sad
Pr, RC;HMA.TIC 63,00 St'
CAR.1•lAGTJVC",&RPO13.T II,3.tit! O
1yvaCosa OF. C;t;):KSTTtUa7: oti
109,485,24)
f413.:6 'i Ry
=141T.3'RUCTION FEE 101-000.418.000 5954.50 '
4}L,f?a.`3S' tr'HFIC K F L 101 -WO -439-318 $792.2:3
W1'ii HCAL, i+ M 1101-000,421-000 "5.50
IClt.3Mi'R,dE.AL 1rE1r 101-000-410.000 �I"43.t2
1'YUM8140 P'�'� 101-000.419-0T00 1"7�i.`tiQ
STi;J:P.ald`f.4 A+tOTION I14fs • ..W 1€ 1-'000-241-000 $19.95
GiCAi)a'1 O FEE 101- 0•— 4234000
D1` VEIgg.1FIXt IMPACT "It �x,St�.t?tti
MITI 1.VEAL fi°�14�"�'1'�'€ tCM.C'iAH ARD PJAN c �1:�5f %1.62
�."M PRM -.PAID YER S
MOO
'MAL 1'UMU:1 V.1 ES DITE NOW
�fiAR3�.1�a
i
RECEIPT
DATE %
BY
DAT FINALED
INSPECNR
1119
- -
INSPECTION RECORD
f OPERATION I DATE I INSPECTOR
BUILDING APPROVALS
Set Backs f /O— O 2- S
Forms & Footings / —/b — v i
Slab Grade =� p p , _
Steel
Roof Deck
0. K. to Wrap'
Framing
Insulation W
Fireplace P.L. _
Fireplace T.O. _
Party Wall Insulation��
Party Wall Firewall
Exterior Lath�—
Drywall - Int: Lath
OPERATION
I DATE
I INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
POOLS - SPAS
Steel
Ducts
Return Air
_ S
e J
Combustion Air
Footings
Exhaust Fans
Main Drain
F.A.U.
Compressor
Vents
Equipment Location
Grills
Fans & Controls
Final
COMMENTS:
Final
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring y /�
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final -
Utility Notice (Perm) 7 �—U Z
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
Waste Lines
PLUMBING APPROVALS
_
GJ`� �� -jig — O%
Gas Test
Electric Final
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
/�_�
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection�_ �--L cj
Gas PipingJ-14
Pool Cover
Encapsulation
Gas Test
Final
COMMENTS:
Final
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring y /�
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final -
Utility Notice (Perm) 7 �—U Z
CertifiOccupanqy--r=
ca to of
Cit of La Q u�nta
Building and
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: 78-430 VIA SEVILLA
Use Classification: SINGLE FAMILY DWELLING Bldg. Permit No 0112-067
Occupancy Group: R3 Type of Construction: VN Land Use Zone: RL
Owner of Building: CENTUURY AMERICAN DEVEP. Address: 78-520 VIA SEVILLA -
City: LA QUINTA CA. 92253
` By: 'GARY SHOWALTER
Date: 09/03/02
Building Official
_ POST IN A CONSPICUOUS PLACE