0111-190 (SFD)F t - 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
T {•w
err 13 €TIC iRf
Dates" ' 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
r
WORKER'S COMPENSATION DECLARATION
I -hereby'affirm under penalty of perjury one of the following declarations:
O 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.
KATE FUM)
(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 "a d"agree that if I shouldtbecome
subject,to the'wor ers' compensation provisions hof Section 37,00 of the Labor
Code, Lshalf forthwith comply wltli those•prowslons. ' v
Date:,r�:y.. iJ'!' P` Applicant,
Warning: Failure to secure Workers' Compensation coverage is unlawful anpl
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 pursua
any. permit issued as a result of this applicaton agrees to, & shall,.inde i
& hold harmless the City of La Quinta, its officers, agents and employ
2. Any permit issued as a result of this application becomes null and v i if
work .is not commenced., ithin 180 days. from date of issuance of h
permit, or cessation of work for 180 days will subject permit to cancell ion.
I certify that l have read this application and state that the above informati n is
correct.,I agree to'comply with all City, and State laws relating to thebui
construction, and hereby authorize, rep resentativ�s'of this City to enter. upo
the above-mentioned property. fdryinspecti n purpos s. s.• / e
Signature (Owner/Agent) -~" 7. Date, ff '
Vs:}
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 0111, 90 TRACT
23 27443-2
JOB SITE
ADDRESS 49L-371ITWA XMA sr'fiOL
APN .
649-10D-002 ;x.
OWNER
CONTRACTOR / DESIGNER / EN (NEER
I-Al.QTJW_F CA 922S3
I..AQUINIA C'r'y, -42213
(760)T73-1941 C`.$3ut '2996
USE OF PERMIT
'�.iy"kA^��C33.1.+:��va:��+`i):i.V1.1p3:,A°.f•�:gClTii�1:t?�r.���7�R f{�p
.,
p rye+et, H ,tc9 ee�79 P fir• �1p t e
A '. Ai4E8 �.�,4�'0..N-)itl lVi i. .f'J:N1.�1�A N6.+4,w1 �i ��d iA�L•lai.l /Jfi /.�✓t.rW}�..M,r v9 �if.rf J,,i �r
�g�0.POOL�
Q11PA OR DRIVEWAY APPROACH
CUIR0.MCONS1" Ur,.Y'3QN :,w'm3F
PORCHII-'A` IO 530.00 Mott
`
0o^9,RAMYCARtPORT 693.00 'IF
nmMO O COSH O
r MMMY
COIy4"1'.t:UC73ON Pf1`E I01' 000-418.000 V;280.00
PIAN CHECK WE 101.000-439.318
tel? 101 -000-421 n000 $149,50
'PLU."f KrI AL FAX, 101-000-14120-000 $215-.04
1'LCaikC1?INO �?%? 101-00.0-419-000 210,2,:t5
S t'ilt2i+ D MOT50NMI> RIOX1.0 101,000-2411-000 $33.21
ORAD INO ME 101-000-423-000 $20.00
D,Ir'W't?IDPER, IMPACT ME �D,907.6H}
AF,T W4 1't BTAC $'1.ACE3 - 3tEME 270-000-445-W $205.27
- WMmIXYrt4. L'°C3M'CI CAt:'�.`kU2+1'AM PLAN C1117e K
$51064.17
,14 , UMS FRE -PAID HIM
DEC u b :�a�q �ry-lt lirf�Fatsvp mot,
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BYE®�LAQUONY�+~` S
_
RECEIPT tx
DATE ; ,
BY
DATE FI LED
INSPECTOR
INSPECTION RECORD
OPERATION j
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
,
MECHANICAL APPROVALS
Set Backs
Forms & Footings
Slab Grade
_ t
Z v
- 3�p `Z 1p
Underground Ducts
Ducts 3 -1�-9
Return Air 7 /Z!!: , F4. 1E
Steel
Combustion Air
Roof Deck A'f.} • 1
2 _ 7 —v _s
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
3 -�2 -. Z
_
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
_ O
I
.
Final
Final
�j=�
'
POOLS -SPAS
BLOCKWALL
;—O�
APPROVALS
Steel
Set Backs
I
Electric Bond
Footings.
I
Main Drain
Bond Beam
}
Approval to Cover
I
Equipment Location
i
Underground Electric
II
Underground Plbg. Test
Final I;I
Gas Piping
PLUMBING APPROVALS
Waste Lines _T-0 /J
Water Piping �O
Gas Test
Electric Final
Heater Final
Plumbing Final
Plumbing Top Out
I
Equipment Enclosure
Shower Pans
!
OX for Finish Plaster
Sewer Lateral
Sewer Connection/
Gas Piping
Gas Test
f I
Z % Y
/ 6 Z c=0
y — /O =- -.2- S
Pool Cover
Encapsulation
Appliances
I
Final
COMMENTS:
I
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole j
Underground Conduit
Rough Wiring _ l +_
Low Voltage Wiring i00
Fixtures
Main Service +
Sub Panels
Exterior Receptacles loll
G.F.I.
Smoke Detectors }
Temp. Use of Power j
z
1
Final
Utility Notice (Perm) i
( C e, rtate of Occupanc
t Quinta
Cit ofLa
nd~SafetyD.epartmentBuildin aQFA
-ar
"This Certificate issued pursuant_ to the. requirements; of Section : x_09 of .the Uniform, Bui/ding Code, '--
certifying that;:at the -time of issuance, this structure,
was comp/lance with the various ordinances
...
of the City regulating building construction , or use. For `the foil -wing; `
BUILDING ADDRESS.: - • ; f 49-37-1, VISTA' MIRASOL
Use Classification:. SFD Bldg. Permit No:: '0111-190
Occupancy Group: ' R-3 ` Type of Construction: VN' = Land Use Zone: RL.
Owner of Building: ~ TD DESERT DEVELOPMENT. Address:, PO BOX 1716
- City: L'A ~QUINTA CA 92253
By: GARY SHOW -ALTER
•Date:• 6-14-02 . .
Building Official
- POST IN A CONSPICUOUS PLACE. �. - ` ' '