0107-297 (SFD)�.._ _... ala � •-:.�,..
LICENSED CONTRACTOR DECLARATION
'11 hereby affirrin 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.
r License # Lic. Class. Exp. Date
7"18214058 I/A
Date ° `'r i'�� Signature of ContractorINJ
�✓"""-"""-"' °`
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).
( ) .1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
O I am exempt under Section B&P.C. for this reason
Date Signature of Owner
Q WORKER'S COMPENSATION DECLARATION
CL
Ocr I hereby affirm under penalty of perjury one of the following declarations:
<( ) -! have and will maintain a certificate of consent to self -insure for workers'
X W compensation, as provided for by Section 3700 of the Labor Code, for the
m� Q performance of the work for which this permit is issued. `
< C) ( ) I have and will maintain workers' compensation insurance, as required by
O CJ Q Section 3700 of the Labor Code; for the performance of the work for which this
li 0)I— permit is issued. My workers' compensation insurance carrier &policy no. are:
It z Carrier•wwpp II gg����yy ff1 Yy w�v w�C� ' Policy No.
MM 'HWC547014-92
J(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
3 Code;,. I shall forthwith comply with those.provisions.
Date: -� �+ ,-,, f Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawfur? nd
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 1
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 i
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Y.......
Signature (Owner/Agent) Dat
BUILDING PERMIT PERMIT#
f
DATE w y>� / VALUATION LOT 0107-2,911 TRACT
�( } ��
�rJ eii e.:9 b6.e�Jn I rtS••8.. r. 5 2 97 q 5 - {
JOB SITE
APN
ADDRESS ^
1184M VU GIMLLA
7 2-41
OWNER
CONTRACTOR/DESIGNER/EN (NEER
R. C.1-10IRBS COWANYC WC .
LA QUMA
CAif'ING CA 929"
(714)633--7260 C"ALA 5487
USE OF PERMIT
SPO 4TWt1i . ?C.- )?EAMI T,0012 NOT INC1,11D)f SaJi.`'C WAi.LOf OOL 0
4
TRACT CONSTRUCTION %769.00 sr,
'kURIM- PAT 16 1n.00 Sir
EVI AMM C1081'orCONSTRUCT0' 11t
Syi E SUMMARY
.01IIA9TLfiION 1!72 101 -000,418-000
PLkH CYi' EC K FFA 101-0010.439-3 18 t 0°d?fi
MECHAMIC.AL FRF, 101-000-421-000 $93,50 .
W3 f 9'!kd{'t'i8. }>:k1-000.420.000 $243.08
1'U 18"Wo FEZ $169.15
0-2 414.000 $16,i7
PER a ID 101-000-2414,000
:57Rsap�i��Opp�� A�'c"it�(1
01-101-000-423-000
�����yYON
pp��a„
;9v3.G9�'hf�.:lit."dr;E $3,�b7.Df1
7 rlAtlet 1. RU MOM AND )PLARCHECIZ.
J U L 3 0 200 1
.; aifu
RECEIPT
DATE -
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
/
�/ 3�/ l
Underground Ducts
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
_
F.A:U.
Framing
Compressor
Insulation
Fireplace P.L.
/%/ Q (
/
Vents
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final — —�
Final
2-2 ?— 2 5
POOLS - SPAS
BLOCKWALL
APPROVALS
Steel
Set Backs
Electric Bond
Footings
Bond Beam
l JG—
Main Drain
Approval to over
Equipment Location
Underground Electric
Underground Pibg. Test
Final
I
Gas Piping
PLUMBING APPROVALS
_
Waste Lines �3�r
Water Piping
Gas Test
Electric Final
Heater Final
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral—
Sewer Connection-/
Z3 D,S�
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbctures
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
-Smoke Detectors
Temp. Use of Power
Final _ 2 2-2—
-ZUtility
UtilityNotice (Perm) T� •— c2
Cert�ficate'
cCa ancyLa'Qu �nta
Building'and Safety: Department.v. MO>F,
This Certificate issued pursuant to the requirements of Section- 109 of the Uniform -Building '.Code, '
certifying that, at the time of issuance; this structure .vIias.,in_ comp/iance 'vl ith. the ' various ordinances
of the City regulating bui/ding construction or use. For the fol%wing:
- h -
{ BUILDING, ADDRESS: t 78-485 VIA SEVILLA
Use Classification:, SINGLE FAMILY DWELLING ,. Bldg. Permit No.: 01,07-297• _
Occupancy Group: R-3` Type of Construction: VN Land Use�Zone: , RM
Owner of -Building: CENTURY AM ERICAN,13EVELOPMENT Address: 55-487 SOUTHERN HILLS
CORP.
City: LA QUINTA, CA 92253
By: GARY SHOWA.LTER . -
��"'� �Date:02-27-02
Building'Official -
POST IN A CONSPICUOUS PLACE ,