0107-291 (SFD)a.
LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
.04fer.'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
'77V214 n 5131x`02
Date ✓1- `" !Signature of Contractor'��'"'�-M,
�. �r-� ��� _ QWNER-BUILDER-DECEM ATI10.N
I he ' rr
r
reby 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, wil: 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. 70441;° Business & Professionals
Code).
( )' Lam 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:
() I have arid'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 Policy No.
(JO1rlreEN ;P.AL1LZ'1.H,'3: NWCN7014.02
(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 -provisions.
Date:'' -:ire, h � Applicant t` � »- ^• ,....-
.:_.Warning: Failure to_secure-Wo'Fkers' 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 cf 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.
Signature (Owner/Agent), Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT I1��'p..�Sig . TRACT
JOB SITE'
APN
ADDRESS
7q-490 WA SVV91,1,41.
OWNER
CONTRACTOR/ DESIGNER / EN (NEER
n VE CYPW1_1N :f„ cr
d), R (11. ;EId: RBS CXMIPI VY WC".
LA.Q''. 'A CA 92253
ORANGS CA 92966
("i 14)6334260 MIN 54¢.11,
USE OF PERMIT
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TRACT VONSTRUCTION 3. Lt. DO OF
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Es"I'mA`1 D K:L'?su, 4)'
CO14STPIUC 1.014 iMEE 101 ••000.418.000 W. 4.SJ
PL. Ci•.i WK FEZ 2.25
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JUL 30 2001, TM5 PRE) -r- AM F-111138
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$4,1,410a
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t
RECEIPT
DATE
� �!a . , �:%
BY
DATE FINAL D
2 oz..
3-Z-
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
01
Underground Ducts
Forms & Footings
23� j
Ducts
Slab Grade
/
Return Air
Steel
Combustion Air
Roof Deck
_ ��
Exhaust Fans
O.K. to Wrap
Framing
j
f ��
�' _
F.A.U.
Compressor '
Insulation
(f l
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
6-�
Main Drain
Bond Beam
Approval to Cover
yy
Equipment Location
Underground Electric
Underground Plbg. Test
Final
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lin es�Q
C'
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
fthower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connectionc�
_
0-00
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
CC
Final
COMMENTS:
Final
�`�—!''/�%L 911eJ
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
Utility Notice (Perm)
Certificater,of®ecupane
y a
City—of La. Uinta
-Buildin- and Safet Depattment 9► � y M of -�
r
This Certificate issued pursuant to the requirements of Section 109 of the Uniform .Building Code,
certifying that, at• the tune of issuance, this structure was in comp/lance with the various ordinances
of the" City regulating building construction or use. For the following:
_.
BUILDING ADDRESS: 78=490 VIA SEVILLA
` Use Classification: SINGLE FAMILY DWELLING Bldg. Permit No.: 0107291-1
Occupancy Group: R-3 Type of Construction: VN Land ' Use Zone: . RM
Owner. of Building: CENTURY AMERICAN DEVELOPMENT Address: 55-487 SOUTHERN HILLS
CORP:
L 'City: LA QUINTA, 'CA 92253
By: GARY SHOWALTER-
!��'�/� Date: 03 -28 -02 -
Building Official
_ POST IN A CONSPICUOUS. PLACE