0111-197 (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
D BIC`
Date ' `' Signature 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 construct the 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:
(5) 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 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 Cal'fo""rriia and agree that if.l,should become
subject to the ;worl�grs'.compensallon provisions of Section 370'0 of the Labor
Code, I shall tforthwith ,Comply with those provisions. J/
Dater i4 # /' 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 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 auttionze representatives ofj his City to enter upon
the above-mentioned property forinspection purposes.! r
Signature (Owner/Agent) .., f es" ^. 'Date 1 n`
BUILDING PERMIT PERMIT#
DATE VALUATION LOT i�„)).�.—i"I TRACT
""?, 4, 2,94.5 4
JOB SITE
APN
ADDRESS
OWNER
DESIGNER /ENGINEER
CONTRACTOR /
AD Y:ZARYJl2tinYUAv
:..
M3J AVCi&J .Naffryw,
..
PO DOX. 1716
7 9 -Z95 WCHID LA Qum lmra.
I..AQTJ)34TAI CA. x;22.5:3
3:,,f4.Q NTA, CA 92253
(76Oa77:�1941 mut 2996
.
USE OF PERMIT
WICIrT<
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WALLA P001, SPA OR DAMMAXAP.1'ROAt:'Fi
CUSTOM C'OAi:;1'% UCTION 4,321.00 SN
PORCIVPA`I':IO 552,00 5f'
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1101-000-441-000 S,20�100
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RECEIPT
DAT)E /
BY ({ /
DATE FINALED
INSPECTOR
X
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
% _
v
Underground Ducts
Forms & Footings
Slab Grade
/ -Z
,_ �% 8
Ducts
Return Air
Steel
Combustion Air
Roof Deck
O.K. to Wrap
— �_� _
Exhaust Fans
F.A.U.
-�
_
Framing
�— 3_
Compressor
Insulation
:. —ia _ z
Vents
_
Fireplace P.L.
Grills
_
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wali Firewall
_ _
Exterior Lath
_
Drywall - Int. Lath
Final
2 _02
Final_/��
POOLS -SPAS
BLOCKWALL APPROVALS
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
Waste Lines
Water Piping
_
/
Electric Final
Heater Final
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
_
/-.3/ Z �P�
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
—phi S
Utility Notice (Gas)
6 —
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)
_
,
xC
Occu'pancyf
..
Citof L
y
Building -and Safety Department
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'fo/%wing:
BUILDING' ADDRESS: 49-340 VISTA MIRASOL
Use Classification: SINGLE FAMILY DWELLING Bldg. Permit No.: 0111-197
Occupancy Group: R-3 Type of Construction: _ V -N Land Use Zone: R -L
Owner of Building: TD DESERT DEVELOPMEMT Address: PO BOX 1716
i�dr'b"L
10
Building Official
City: LAQUINTA CA. 92253
By: GARY SHOWALTER
Date: 07-18-02
POST IN A CONSPICUOUS PLACE