0112-077 (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
470689 B : poi' 1/02
Date rl/'.2Signature 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:
( ) , 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 constructNthe project (Sec. 7044, Business & Professionals
Code).
O 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:
() 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 (1f LDEN .C.e4ME Policy No. 1`iWC: M791401
(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 foithwith comply with those proivissioonts. w
Date: - .2 _Applicant --w- s
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. F
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.v;'
application.
1. Each person upon whose behalf this application -is made & each person a
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 Quints, 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.
Signature (Owner/Agent) � � Dater
BUILDINGPERMIT
DATE VALUATION $,J*,,4"M LOT
PERMIT # 'n
01112-0117 ,
54 TRACT 23,07 1'
JOB ADDRESS 794W45VIA: EVIU,.�$aA APN 604-21-1.010
OWNER CONTRACTOR/DESIGNER/EN (NEER
M -AMY AWMG".AXTWM0T%Z%r, , CO: W. C:-ENa.iMMA3 VCAW 1 1IVEL.CsnM3. 'r, ox
r'8, 52 J VhA v 6r: t 13-520 Wh OBVIC1:.l'f: A
Imo.Q17.IW A O.Ati .92:253 LAQ(TNTA C?A v2153
(760)564-MIZ MO. 54S7
USE OF PERMIT
t3Y.10 c ratl I 3r/, t-d.WtJ'4 J%,95.. d-GLtiFYd4I IJ4.1r-1 11111 1111. J
WAA6.4A i'3'C►M '1904 OR DRIVEWAYAPPROACH. CH..
1.11RACT 'CONSTItUCTION MAW SF
PO12CHIPAT'IO 63.00 S
GAiLAt3MA RPORT 1692,00 i%
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UTMAL PIMFel:£EMS '1Yi1i". NOW $4113:1172
HSR 07.2002
CITYOjjeCA��1P�
RECEIPT DATE BY DALE FILED — / INSPECTOR
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�!S
�. kTw,,r PE, E r83I`vi>tRl ARY
L'O�d`1'13GgClfC! i�'
1014 0,41U-000
$0.5
PLAN CH81 MK FN '
1.01-000-439-a18 39-a'1.1
1792.25
MECILANIC"M
101.000-421.000
S81415
LP.t+.c TR.JCA1.1:`RE
101-000.420-000
9174.12
PLUMBING FEE
101-000.4190 OOO
$114.50
STRONO MOT1014 FEX,- 1WID
101-!000-•241-000
$18.:93
ORADIWO ITU
101-000443-000
$20.110
13E1+•E1A)PER IMPACT 1+ ..`r
$1,907,00
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UTMAL PIMFel:£EMS '1Yi1i". NOW $4113:1172
HSR 07.2002
CITYOjjeCA��1P�
RECEIPT DATE BY DALE FILED — / INSPECTOR
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�!S
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
3— _ yz—
Underground Ducts
Forms & Footings
r/ — _
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap '
— -
F.A.U.
Framing
- /Q - a z
Compressor
Insulation
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
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
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines �'
3-- . Z
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
I Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
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 -O Z
Utility Notice (Perm) (D -d 2- 57
COMMENTS:
Certific'ate.of a
CityQuintaof La
Building and SafetyDepartment 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 compliance with the-various ordinances
of the City regulating building construction or use. For the,following: _
BUILDING ADDRESS: 78-495 VIA SEVILLA
Use Classification: SINGLE FAMILY DWELLING Bldg. Permit No.: 0112-077
Occupancy Group: R-3 Type of Construction: VN Land Use Zone: RL
Owner of Building: CENTURY AMERICAN DEV. Address: 78-520 VIA SEVILLA
City: LA QUINTA, CA 92253
By: STEVE TRAXEL
Date: 11-06-2002
Building, Official
POST IN A CONSPICUOUS PLACE