9907-115 (SFD)4 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
f!Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp., Date
47868' ;73 02!2912(
Date �. , S,�fSignature of Contractor
^mss i
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).
() 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.
( )-!,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:
CarrierGOLDEN OLR POlicy No. N1VC 547701400
(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 forthwith comply with those provisions.
Date:
,Li) Applicant 11A.-
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+ot 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 authorize representatives of this City to enter upon
the above-mentioned property for
�inspection
_purposes.
Signature (Owner/Agent) --� V'�'� Date"� `=� 9
BUILDING PERMIT PERMIT#
DATE VALUATION
XLOT TRACT
1,22.3,10 . =2> 1118603
JOB SITE_ APN
ADDRESS "� �m 761^10-048
OWNER CONTRACTOR/DESIGNER/ENGINEER
SOTTifFERAl'HII ,S 1:LC RC. ROBBS Ciba SOUT1^LERNxFD ZS, LLC
1430 E C11APMAN AVE STE 100 55.960 POA BLVD
ORANGE GE CA 92616 LA, Q1(TtWA CA 92253
(714)633-7260 C131.A 5487
USE OF PERMIT
SACT .F 1+AMILY ME.3. IRiG
SFD • LOT 2 PI..KN 3A P'ERMI'T DOES 'NOT INCLUDE BLOCK WAL1, OR
POOL.
CUSTOM C014STRUCTION 3,465.051 SF
P017.C711PAT10 $36.00 SF
GARAGE(CARPORT 723.00 SF
EF'J"fe UTED COS' OF CON UC` 014
291,22:3.10
CONSTRUCTION FEE
101-000-418000 ��
87,911,50
PLAN CHECK IEE
101-000-439-318
$1,076.28
ME.CRM ICAL VEZ
101-000421.000
$118,00
ELEC' rUCAL FEE
101-100-420.000
$193.24
PLUMBING FEE
101.000-419-000
5243,00
STRONG MOTION FRE • RESSU3
101-000-241-000
$29.12
GRADiNO FEE
101.000.42.3-000
$20,00
DEVELOPER IMPACT FEE
$1,90?.0t1
ART 1N PUBLIC; PLACES - RES] C701.000.255.000
S229X6
SUB TOTKk- CON lYCTION AND IPII., W CBECK1. I $5,126.20
S PRE -PAID 1.1 .E $0,00
TOTAL P:0.R11f18 F'1 S :DTiTE ,1.10W II $1511.�►.20
RECEIPT I DATE I BY I DATE FINALED I INSPECTOR
INSPECTION RECORD
iOPERPTION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
I I
Underground Ducts
Forms & Footings A•
waft
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Ol
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
InsulationVents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewa9
17
Exterior Lath
Drywall - Int. Lath
/
Final
Final I V -MI -01 S
BLOCKWALL APPROVALS
POOLS -SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Ow
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connectior:
Encapsulation
Gas Piping
Gas Test
D
Appliances
Final
Final
Utility Notice (Gas$
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 :2 143
Utility Notice (Pere)
COMMENTS:
MAR -06-2001 14:54 WESTERN INSULATION 909 686 8786 P.03/09
MESTERN INSULATION, INC.
4211 Tatham Street, Riverside, California 92501
7r:L (909) 686-8760 Pax (909) 686-8786
INSULATION CERTIFICATE
THIS IS TO CERTIFY THAT INSULATION HAS BEEN INSTALLED IN CONFORMANCE WITH
THE CURRENT ENERGY REGULATION, CALIFORNIA ADMINISTRATIVE CODE, TITLE 24,
STATE OF CALIFORNIA, IN THE BUILDING LOCATED AT:.
TRACT / PHASE: #28603-2/ PHASE 4
LOT #: 2
SITE ADDRESS: (40.41 a'RIVIERA.. LA., QUINTA, CA
EXTERIOR WALLS -
MANUFACTURER: JOHNS MANVILLE THICKNESS: 5.5 " R -VALUE: R-21
CEILINGS: BATTS
MANUFACTURER GREENSTONE THICKNESS: 16 1/4 " R -VALUE: R-38
CEILINGS: BATT BLOW
MANUFACTURER JOHNS MANVILLE THICKNESS: 10.3 R -VALUE: R-38
GENERAL CONTRACTOR: R.C. HOBBS COMPANY
BY:
TITLE.
DATE,
INSULATION CONTRACTOR: WESTERN INSULATION, INC.
LICENSE NUMBER: 481278
BY: At
TITLE: PR D CTION IWANAGER
DATE MARCH 6, 2001
t