0112-072 (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.
License # Lic. Class Exp. Date
478689.
Date t �/ 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:
( ) 1, 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 Signature of Owner..
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty, of perjury one of the following declarations:
O 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.
( )r 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 0O;UMN FAME, Policy No. 2Mr, S 01401
(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, I shall forthwith comply with those -pr visions.
Date: 12, e L. � Applicant
14
--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:d 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
S'ignafure (Owner/Agent)'""'Date ` - CAW
Y,. .
PERMIT #
BUILDING PERMIT
DATE VALUATION LOT 0111-072 TRACT
v- /J1. -e: p o-�:t}:, ," 60 1 23973.1.
JOB SITE
APN
ADDRESS 78-4:5 VIA.IApVI IA,
04-212-J007 I
OWNER
CONTRACTOR/DESIGNER/EN INEER
i;�.+,�v""� ARY AM'1^'�%C°.A,13 DEVEUJPNZ=, Col
ZP. , UT -1i l .P tCM `DF"V3i°L,0 M1F `r1 COB
LA QUW.4.A O.A. 92253
1A QwyrA C.A. 92253
? �2a5 h�5ts i C}3I 548?
USE OF PERMIT
D7�i�3};o� �J'7.�!Y.0.!✓�r .6.J Yt'i:si'w]��.,7
2,07) ,d0S 0,TF,'3A.:PSWI l?ES lq(YtlNCi,13OE3.LOCKWALLA
P004,6M4R DRIVx9AYi-7iORCH, -94 PLAN EHf41K M
Ra:OalCTION FOR MULTIPLY, ISSUANCE OF 10A i< 1,A§4 TY1$9
TRACT CON10TRUCTION %228,00 OF
aiy?
P(�LppdytyyZ,yOgqkr�f((lpt' AT;►IOC
�e^y�;2S�y rty6y37.00
rJAX.R'-0��.JVO«�•�3�.1S5. Rtl� t:Uk.4Ki i+1�R'
R'IYTED CO.Vr or CONSTR ON
189,405,50
,.
PEYVyyE0 7yR1Ap$Y
C',01401'Ji?°UCTIOO W, 101 -000.414i, -N00 $9SM
.PL,A.W CllF:, XV, ME 101-000-439-318 $199.65
MEC' AMICA , Rle 101-000-421-000 81"
�'9.k.C: a hZ0AL, YHf? 1.0:1-000-420-.000 �ib�9.ad
Farr
0%2M,tQNO P1?9 101X000-423-000 $aCt,p(t
7..i1,VV4J_A1ZR IMPACT V.VY,
SUB -` t'DTAL CONST1~.'UCC11 M ANtP P MT ME MX
$3,537.63
X,;ir;M FR •:FAJDInKES`
20100
rVUL 101" 111 ow
nr VETS DUE
RECEIPT. I'
DATE
BY
DAT ALE
INSPECTOR
P.
f
INSPECTION RECORD
OPERATION DATE INSPECTOR
BUILDING APPROVALS
Set Backs
Forms Footings
Slab Grade _
Steel
Roof Deck 2 —� /—� �• �—
O.K. to Wrap 3 j;EZFramingInsulatinn.. 7
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation Z V
Party Wall Firewall
Exterior Lath
Drvwall - Int. Lath 1 1/
Final I I
BLOCKWALL APPROVALS
Set Backs
Footings
Bond Beam
Final
I I
PLUMBING APPROVALS
Waste Lines
Underground Ducts
Ducts
Return Air
Water Piping
Plumbing Top Out
Shower Pans
Exhaust Fans
Sewer Lateral
Sewer Connection
Gas Piping
Compressor
Gas Test
/D. A S
Final
ELECTRICAL APPROVALS
Temp. Power Pole
Underaround Conduit
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temn. Use of Power
Final
Utility Notice (Perm) ��"�'
OPERATION
DATE
INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Final
Steel
Electric Bond
Main Drain
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Gas Piping
Gas Test
Electric Final
Heater Final
Plumbing Final
Equipment Enclosure
O.K. for Finish Plaster
Pool Cover
Final
COMMENTS:
POOLS - SPAS
Certificate of Occu-pancy.
City of La Quinta
Building and Safety. Department �°<Mo,.�
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 following:
BUILDING ADDRESS: 78 -435 -VIA SEVILLA
Use Classification: .SINGLE FAMILY DWELLING Bldg. Permit No.: 0112-072
Occupancy Group: R-3. Type of Construction: VN Land Use Zone: RL
Owner. of Building: CENTURY AMERICAN DEV.
Building .Official
Address: 78-520 VIA SEVILLA .
City: LA QUINTA, CA 92253
By: STEVE TRAXEL
Date: 02-12-2003
POST IN A CONSPICUOUS PLACE