SFD (9910-056)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
IQharnr 9 (commencing with Section 7000) of Division 3 of the Business and
essionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
ry )16.s 1 u � U' �1b
Date Signature of Contract or
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.
( ) 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 California, and agree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I sha fo hwith comply with those -provisions.
Date: Applicant r%P- t��:�s.r,_ JP1N.,J`,
k
Warning: ailure 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 authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
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Signature (Owner/Agent)' T - ", t a �)�-, * Date
PERMIT #
BUILDING PERMIT,,#
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SITE
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USE OF PERMIT
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RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
S, .
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
^
15"
Underground Ducts {
Ducts {
Slab Grade,
Return Air i
Steel
Combustion Air. I
Roof Deck
O.K. to Wrap
Exhaust Fans
F.A.U. 1
Framing
/ �',�
Compressor g .
Insulation3—
7 pU
Vents {
Fireplace P.L.
Grills {
Fireplace T.O.
Fans & Controls {
Party Wall Insulation
Condensate Lines {
Party Wall Firewall
I
Exterior Lath
Drywall - Int. Lath
%
(®
y
I
I
I
Final {
Final
POOLS - SPAS
BLOCKWALL
APPROVALS
steel {
Set Backs
Electric Bond 3
Footings
Main Drain t
Bond Beam
Approval to Cover i
Equipment Location
Underground Electric 1
Underground Plbg. Test {
Final
Gas Piping 1
PLUMBING APPROVALS
Gas Test y
Electric Final I
Waste Lines
_0n-2 =9 ? -
Heater Final I
Water Piping
Plumbing Final {
Plumbing Top Out
Equipment Enclosure I
Shower Pans
O.K for Finish Plaster I
Sewer Lateral
Sewer Connection
Pool Cover {
Encapsulation -
Gas Piping — —&C.-
Gas Test
t
Appliances
Final I
COMMENTS:
j
!
i
iii
Final O jj
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 vv
Utility Notice (Perm)
'IAY-18-2000 11:54 WESTERN INSULATION ` 90�':) F)6 8746 P.08/13
WEST I Si��;L�►"TI ` 11T, INC.
4211 Latham Street, Rhvcrsidc, QUiCbmia 92501
Tel, (909) 686-8760 Feu; (309) 585-8786
INSULATION (": oRTIFICA'TE
THIS IS TO CERTIFY THAT INSULATION HAS BEEN INSTALLED IN CONFORMANCE WITH
THE CURRENT ENERGY REGULATION, CALLIF'dRNIA ADMINISTRATIVE CGDE, TITLE 24,
STATE OF CALIFORNIA, IN THE BUILDING,LOGATED AT:
TRACT / PHASE: BELLA VIS''A -'TRACT # 28458-1
LOT# 19
SITE ADDRESS: 43830 MIL4N COURT LA QUINTA, CA.
EXTE:RWR WALL 1:
MANUFACTURER: Johns -Manville THICKNESS: 3 5/8" R -VALUE; R-13
CEILINGS: BATTS L'OW
MANUFACTURER:. Greenstone THICK.NES& 10.3" R -VALUE: R-38
CEILINGS: TTS i BLOW
MANUFACTURER: Johns-M'arvil/e THICKNESS: 13" R• -VALUE: R-38
GENERAL„1)NTRACTOR: TRADITION�kL BUILDERS
LICENSE NUMBER:
BY:
TITLE:
DATE:
INSULATION CONTRACT -01 WE.STEFtN INSULATION, INC.
LICENSE NUMBER: 481178
BY:
TITLI_: PRO U TION MANAGER
DATE May 18, 2000