0112-083 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions Of
Fes— t' Chapter 9 (commencing with Section 7000)'of Division 3 of the Business and
''^✓i
CV UJ Professionals Code, and my License is in full force and effect.
m ch. License # Lic. Class Exp. Date '
cZ r,_Date -Signature of Contractor
CD D
J U 0 : OWNER -BUILDER DECLARATION
LU LU I hereby affirm under penalty of perjury that I am exempt from the Contractor's
a.
U) 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).
co" (" )� 1 am exempt under Section B&P.C. for this reason
Lr)
N Date Signature of Owner -
rn
Q. WORKER'S COMPENSATION DECLARATION
p � I hereby affirm under penalty of perjury one of the following declarations:
Lo H p O I have and will maintain a certificate of consent to self -insure for workers',.
X WL - compensation, as provided for by Section 1700 of the ,Labor Code, for the
mJ Q performance*of the work for which this permit .s Issued.
Q U O 1 have and will maintain workers' compensation Insurance, as required by
O L)Q . Section 3700 of the Labor Code, for the performance of the work for which this
Il LO H permit.is Issued. My.workers' compensation Insurance carrier & policy no. are:
? " Carrier Policy No: NWC° 54701401
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g (This section need not be completed if the permit valuation Is for $100:00 or less).
O 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 prouITions:
Date: -Applicant
Warning: Failure, to secure Workers', Compensation coverage,is'unlawful and
shall subject'an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of.compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building•and, Safety..
for a permit .'subject to the conditions and restrictions set forth'ton 'his;' c
application. `
1. Each person upon whose 'behalf.th'is application is made &each person at '
whose request and for whose benefit work is performed under or pursuant to
any -permit issued as a result of -this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees. rl,
2. Any permit issued as a result of this application becomes null and void if r
work is -not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above` -information is
• correct. I agree to comply with all City, and State laws relating to the buildin
construction, and hereby authorize representatives of this City to enter upof3
the -above-mentioned property for inspection purposes. .z
• � r
Signature (Owner/Agent) Date'"?� `
BUILDING PERMIT PERMIT#
DATE VALUATION -LOT < ` TRACT.
JOB SITE-
APN
ADDRESS.
OWNER
CONTRACTOR / DESIGNER / EN (NEER
erknup' r :ia.IlmlcAN CO
W. CON
1AQTl":1�!"E`t CA, 922.:23
LA`rt+�z.3.1i��f ,A C:Ae.�'s°��T%',253
.
�74 V S>e°7•n$ 1 i 0' `487
USE OF PERMIT
"SO') WT 21, PJAN 11M YP;RA T TJO s `POT INCLVJ'ON SL OCF i
JPA
%ZIDUC;;TION PDR,. M.UIAdPitA, ISSUANCE OF :"E PLAN T10-9
9 :
TRACT CONS` YCOCP.tON 023.00 SF
PORC".H7PATIO 6 .40 SF
'
29,M&MID COST 011' CUn�"MUC!'.I`, M
1$3i`M #
01 -/Uy(/��0-418••rJiq 0
4pis`ty'ko�.€it�G/'��'yI(liqm 101-000-48-000
j'9qC9
Mt ).M C113fix".T0., T.4W+' did ^'S66AU'��J �- DYJ yA7�•VV.
25.50 -
V#5E.CeH.A Ii'AL Ffl,Lt' 101X000-423-000 S05.50 -,
lei uG0-��:o••f.1�1^ ��,�,%�
PL11R!!BRIQ FEd 101,kW0.41 -000 3114.50
w" PCEN0 Ind II-ITIC1','f FEE — RM! 101 -000-241 -000
DEVELOPER IMPACT FEE S9,Q.kYy.Q��
`WDI-r SAL CO2�d� .C.��[�1', ON A:;.�':i� P .24 me 1p 11C
� :4,337. A
,
¢ '
P i•�TA__
i +mow )XIE NO
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t�4A77
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• MSN If�J I�'�"'l'.�yg,�pfS{�H i A }va. '
REGEF �' lr ti a a
ijATE, n
BY :-:,.
FIN &
SPECTOR
P.
INSPECTION
RE.6ORD
OPERATION
DATE
INSPECTOR
OPERATION
r. DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
3- /�/-Z
Underground Ducts
Forms & Footings
Slab Grade
_
Ducts
Return Air
- v
Steel
Roof Deck
O.K. to Wrap
^ /�% - L _ _
-02 _ -
pL
Combustion Air
Exhaust Fans
F.A.U.
--h� -
Framing
Insulation
_ - _
Compressor
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
�� 3
POOLS - SPAS
Final
BLOCKWALL
_
_
APRO
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
I
Gas Piping
.PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
_
Heater Final
Water Piping_
Plumbing Final
Plumbing Top Out
92,
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
—J;Cy
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas) / I Vii✓
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring - - C,
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final - — -
Utility Notice (Perm) Q •• 1; Ct i �-
C . ertific.ate o
f Occupancy.�. , T .. .:
0JA
Cit. of -La 'Quanta F
B-ilding and Safety Department OF
This ;Certificate issued pursuant ,to the -requirements of Section 109 of the Uniform Building Code,,
certifying that,. atthe time of issuance, ' this structure •was"in compliance ;with the various.ordinances,
of the City iegu/ating building construction or use. For the following: -
BUILDING ADDRESS: 78-390 VIA SEVILLA,
Use Classification: SINGLE FAMILY DWELLING -Bldg. Permit No.: 0112-083
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: BILL GORDON ..
Date: 12-30-2002
y Building Official .
` POST IN A CONSPICUOUS PLACE , . '
ef
A ;
C . ertific.ate o
f Occupancy.�. , T .. .:
0JA
Cit. of -La 'Quanta F
B-ilding and Safety Department OF
This ;Certificate issued pursuant ,to the -requirements of Section 109 of the Uniform Building Code,,
certifying that,. atthe time of issuance, ' this structure •was"in compliance ;with the various.ordinances,
of the City iegu/ating building construction or use. For the following: -
BUILDING ADDRESS: 78-390 VIA SEVILLA,
Use Classification: SINGLE FAMILY DWELLING -Bldg. Permit No.: 0112-083
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: BILL GORDON ..
Date: 12-30-2002
y Building Official .
` POST IN A CONSPICUOUS PLACE , . '