0107-292 (SFD)'LICENSED CONTRACTOR DECLARATION
CFhereby affirm under penalty of perjury that I am licensed under provisions of
.hapter;§ .(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
Date �'` Signature of Contractor:: o
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&RCAO 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 theL'abor 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 per of the work for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
(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,forthwlto comply with. th so eyrovisions.
Date ._., '!, 4L 1) d Applicant .�'
Warning: Failure to~secure wWorkers' 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. 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
r'o
Sign to ure (O nw er/Agent) `Date / r
BUILDING PERMIT-- PERMIT# {
DATE ^^ f / VALUATION LOT (j�ELj'f- TRACT
JOB SITE
APN
ADDRESS
'M -4W VURRMLA
OWNER ,.
CONTRACTOR / D•ESIG�yNEe4RP/.EN,61NE•ER
!'� .rr�q� VN' �..
l,.iu.'�}.QLTRYA"' ..✓..•AICA RIN J.�LO .I.V.4E�A(.V.S 001P.
'''
�f1 CA-14-�BBS V`wsY.M.=ANY �i��e '
55r.4.trli:'c.14^&OqHAJA
'14it0F. CTW'WVNAV
1A QTJM-A CA X5:.23.3
CTRANGE �9�1 :�2�4dae5
(714)KA3-17260 CRL4 340.
USE OF PERMIT
SM - 'IAN 't?kjs PEWMIX`j;' ):)DFX, 1400 INC LUVE 01.0=3. WAUJUPOOL OR
TRAC1' f;t3.4 a7 UC TION %09 SY
PORC HWAT16 0.120
0AIcPi,OMA3CP;?R'i 2.R➢41 S.'
COST Ira r COM?fRUC110N
1. 318 -50
gESTIN:TA,'�:
5"'�i.VdL4.A�a9 Yl..i��17 H.J iff.4A7tSQ'�Y1T9. o.
WNTRUCTiON ME 10 1 -OW-41 $,000 V5440
VVEC1IANICA3LY 101-000-421-000 SUM
CLEC'f:RIC A C ME 101,000-A.,20-000 $179.) 2
P1,bI."MSINa'Pep 10. 000A19-000 WA,sn
szwl4p M0 n014 RESID 101 _000_2,401�(Y)o $118.95
3i2 Tal? C9.wIF .. 101 • C!!J(3=� . 3�CtO� $20.00
�• - tU93 P1W,-PAMRK6S
$0,00
JUL 30 2001I
IPIMS DUE' NOW
&%N.37653
Cll! 0f A
F;k,%rrCi r�EYi
RECEIPT
DATE/FIN
LED/, r�
INSPECT R r
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
Set Backs
Forms & Footings
Slab Grade
_ _ _
Q,
Steel
Waste Lines
_
Roof Deck
O.K. to Wrap
Framing
_
Insulation
Fireplace P.L.
Plumbing Final
Plumbing Top Out
Fireplace T.O.
Equipment Enclosure
Shower Pans
Party Wall Insulation
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
Party Wall Firewall
Pool Cover
Encapsulation
Gas Piping
Exterior Lath
Gas Test
Drywall - Int. Lath
BLOCKWALL APPROVALS
Set Backs
Footings
Bond Beam
OPERATION DATE INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor v� L
Vents
Grills
Fans & Controls
Condensate Lines
Steel
Electric Bond
Main Drain
Approval to Cover
Equipment Location
Underground Electric
Underground Plba. Test
POOLS - SPAS
Final I
I
Gas Piping
PLUMBING
APPROVALS
Gas Test
Electric Final
Waste Lines
_
Heater Final
Water Piping
�/
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
_
8/2 !�
Pool Cover
Encapsulation
Gas Piping
Gas Test
t it
COMMENTS:
I Final
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rounh Wirinn el n — -7 G c
Low Voltage Wiring `—
Fixtures
Main Service _
Sub Panels
Exterior Receptacles
'A2
G. F.I.
Smoke Detectors
Temp. Use of Power
Final �f/ -
Utility Notice (Perm) �=,�
r Micate'o f. OccupanCe tY.01a
City of La Qdinta
- CFM
Building- and 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 comp/iance•-with.-the various•ordinances '
of .the City regulating building construction or use. For thet fo/%Wing:
BUILDING. ADDRESS:. 78& 480 VIA SEVILLA
r
Use Classification: SINGLE -FAMILY DWELLING Bldg.. Permit No.: 0107-292
Occupancy Group: R3* Type of Construction: .VN Land Use Zone: RL
Owner of Building:" CENNTURY CROWELL�COMM. _. Address; 1535 SO."D" STREET,STE.. # 200 _
4 City: SAN BERNARDINO CA. 92408
r
t By: GARY SHOWALTER
Date: 08/12/02
Building Official
POST IN A CONSPICUOUS PLACE