SFD (9910-059)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I'am licensed under provisions•of
Chapter19 (commencing with Section 7000) of.Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
Liceppe # ' Lic. Class Exp. Date '
Date /Si gnature 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
cohtractors•to construct the .project (Sec. 7044, Business &' Professionals
Code).
O I am exempt under Section B&P.C:• for this'reason r
Date Signature .of Owner '
WORKER'S'COMPENSATION DECLARATION' �c
I hereby affirm under penalty -of perjury one of the following declarations:
O I have -and will,mainfain 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' compensatiori 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, iio. are:
Carrier .. . ' Policy'N0.'
OG66356-N„
(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 sJ�al�f with comply with•those provisions. ,
Date: its?tjAPPlicant ,IYi/1pi .
Warning: allure 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 ;restrictio'ns set-foith on his
application. o }
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, in
& hold harmless the City of La Quints, its officers, agents and employees.
f 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) Aon V- J'ZL, W,� Date
BUILDING PERMIT PERMIT# ;.
DATE .jGgft7j,t)gD)VALUATION S110W.�31:4.+4' .} . LOT • flan". ..�:..-,�,- �:.,.'�TRACT
JOB SITE Y
ADDRESS +�.�� S HILAN C URT r
APN
64w41,70-iIm
OWNER
CONTRACTOR /ENGINEER
i.DiSiCED
•y/DESIGNER
}L.0SI�e�/p
�,i-•ii:,+
CA 92253,
LAQUIM-A CA. 91253
2: Cobi.4 575M .
USE OF PERMIT
SINGLE MILING
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RECEIPT
DATE
BYDATE
FINAL ED -
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs {
Underground Ducts
Forms & Footings
Ducts
Slab Grade l/_tea -9 6
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Exhaust Fans
F.A.U.
��•
` �p—
! 3 v
O.K. to Wrap
Framing / —
Compressor
Insulation __ �—rjp 6'e�
Vents
E X
Fireplace P.L.
Grills
Fireplace T.O.
Fans 6 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath�2
Drywall -Int. Lath
/
Final
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
Electric Final
Waste Lines _®==cc�of �,�L
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Encapsulation
Sewer Connection
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
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
Utility Notice (Perm)
P1AY-'�8-2000 11:55 WESTERtJ INSULATION
I 909 686 8786 P. 11/13
a
4211 LaT3 am Street, Rhereiac,; CeMernia 92501
Tel. (909) &16.8760 Fw: 0309) 686-8786
MILT
INSULATION -C, W
THIS IS TO CERTIFY THAT INSULATION HA5 'SEEN INSTALLED IN CONFORMANCE WITH
THE QURRENT ENERGY REGULATION, CkLIFORNIA ADMINISTRATIVE CODE, TITLE: 24,
STATE OF CALIFORNIA, IN THE BUILDING LOCATEE) AT:
TRACT / PHASE: BELLA VIS! -A - TRACT # 26458.1
LOTS' 22
SITE: ADDRESS: 43845 MILAN COURT LA QUINTA, CA.
EXTELR R WALLS:
MANUFACTURER: Johns -Manville THICKIVIcSE: 3 5/9° R -VALUE: R-13
CEILINGS: BATTS . BLOW
MANUFACTURER: Greenstone THICKNESS: 10.3" R -VALUE: R-38
CEILINGS; BATTS SLOW
MANUFACTURER: Johns -.Manville THICKNESS: 13" R -VALUE: R-38
®ENERAL Ct)NTRACTQR: TFLADITIONAL BUILDERS
LICENSE: NUMBER:
BY:
TITLE: ,
DATE.
INSULATION CONTRACTOR: WESTERN INSULATION, INC.
LICE14SE NUMBER: 481278
BY:
TITLE:PRODU LION MMA69R .
DATE May 18, 2000