0107-295 (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, arid. my License is in full force and effect.
License # Lic. Class Exp. Date
Date�Signature of Contracto_rf�"��+
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).
(•) I am exempt under Section B&P.C. for this reason
Date i 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. My workers' compensation insurance carrier & policy no. are:
Carrier 'a qq•�,� yy�� ii C, Policy No. Spy�W,�A�yy��,gg ry„yy
..(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.fany manner so as to become subject to the
workers' compensation law's 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,previsions.
Date:' Applicant
77
Warning: Failure to secure Workers' Compensation coverage is unlawfu'(and
shall subjectan 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 isnot commenced within 180 days from date of issuance cf,such.
permit, or cessation of work for 180 days will subject permit to.;cancellation,.
1 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. tF
Signature (Owner/Agent) _ ���°"^"' Date
BUILDING PERMIT PERMIT# 4
DATE VALUATIONLOT(}?�- f§ TRACT
JOB SITE ' l
APN
ADDRESS 'yy ({/yqy qy�� g �y ) q
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OWNER
CONTRACTOR/ DESIGNER / EN INEER
a�1"�k�➢':t8.J''RY AbWRICAW TAZWELOPWN P CC? •
P. 11.. C. HOBBS CC)1tr—A1+3Y INC
LA QU MITA CA 92253
MANGE CA 92866
(714)633-7260 Ck3Ir4 540
USE PERMIT
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Cif'! C` ILI Qi!I?;;,its-
RECEIPT'
DAT
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap ld YE0/
F.A.U.
Framing
J 6 .� (
_K
�7
Compressor
Insulation
l(—�?�. p (
S�
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
/ !-8 • B C
S7
Drywall - Int. Lath
Final
� • �' • �
Final
_ 7. Z
S
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
Gas Piping
PLUMBING APPROVALS
Gas Test
Waste Lines-�J/,(f
J_
s�
Electric Final
Heater Final
Water Piping
`V /
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
�/�
S�
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
+
Final
COMMENTS:
Final
Utility Notice (Gas)~�
ELECTRICAL APPROVALS
Temp. Power Pole
-
Underground Conduit
Rough Wiring
Lvw Voltage Wiring
Fixtures
Main Service
_
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
=�_
4-iCertific'a -of, 0ccuf)ancV-.-
Q v
Budding and Safety- Department �oF-�°
r
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 fol%wing:. ..
'BUILDING ADDRESS: 78-450 VIA SEVILLA
Use Classification: SINGLE FAMILY DWELLING Bldg. Permit No.: 0107-295
Occupancy Group: R-3 Type of Construction: VN Land Use Zone: RM
Owner of Building: CENTURY AMERICAN DEVELOPMENT Address: 55-487 SOUTHERN HILLS
CORP.
City:
LA QUINTA,, CA 92253
By: GARY SHOWALTER
Date: 02-27-02
Building Official
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