SFD (0203-293)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
ce s s R es mc') 9AIM3
`'. �• ! �.
Date �� f�, ��' Signature of Contractor ��%• 1' t•�•°
7 f�
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 STATE IIJNX) Policy No. 16.014616.02
(This section need not be completed if the permit valuation is for $100.00 or less).
(y)'_I certify that in the performance of the work.for which this permit is issued,
1 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 W1114,those provisions. -
Date: •, is t'- Applicant
Warning: Failure to secure Worke s'- 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 informationds
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.
M
Si nature (Owner/Arlenfi �y" ��jf fir Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 0203-'2 TRACT
333JU65 %k14ir�1
JOB SITE
APN `
ADDRESS
OWNER
CONTRACTOR/DESIGNER/ENGINEER
UMMLORK LP,
WD DW, IMC
74.7601110-HWAY 111 4.200
lit 600131011WAT 1.11
11~1MA1v` wai: u CA 92210
LA Q11INTA Coft. 922513
USE OF PERMIT
Stat -131,110.31, OMIT 6t PL,A'N IR . PrwONT nol?S 1,1(yr 1WCLUDE
Pot))- smalOck w..A.LW% OR DR41rKWd►V APPRCJACH., 75% i1�9"rt 'N
IN PLAN C;HWO K, PEZ 1:0R MU VTIPL F ISSUANC1W OF w01Mri, PIAN TYPL?,.
TRACT rrONSTRUC 1014 709.30 HF
P1 1AIT 1'1% MA&MARY
CO3f40 i`RIIC T'1(A4 F;E 1 U1 «0001 4'e 8.000 $343,00
PIAN, CivTO;= FEE 101_1000439-'M 9-'M 04.51
ML�`���I'I�•,�;.,#�� 1U1mt1tPC�m1��0 839:�D
fa XC TR:1C AL fegg 101-000-420-000
L 1 1�dC M 101 -CM -419-000 28$1io
ST RCYNC4 MOTION PEE • RESiD 101.000-'241-000 $71.1130
r
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f�:.:�.gr{•�pa
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/ �,•T p �yy •� �, �M7.��y, ,�c
G,+M+F`IT.CS'.�.4sSi.7.2;L.�d"9 R 111 Pd.A �..,/"!J.`0K.
f3�y /�, S 9
$,1,180.31
LEL I-T%1i,:P.l M FEKES
$0.00
CITy of LAQUINTA
FINANCOEPT TOTAL DUE HIDW
ha
RECEIPT
`
DATE
BY
DATE FI LED
C3
INSPECTOR
L
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Z $
Underground Ducts
Forms & Footings
—,//— o y
Ducts
Slab Grade
—jz -o
Return Air
Steel
_/ — d
Combustion Air
Roof Deck
/O nP
AV- ZIZ— 5-7
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
('17 z—
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
j. S
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
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
7
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)
I� 5ULATI0-N C£KTIFICATE IC -1
�,itt Ac!,dress
Description of Installation
1. ROO;
Thickness (iP.c.-;cs). 13'r
Penal: Numbu
L ct ..,._.
T;: Rcsis:ante (R -Value) 34
2. CEILING
133!: o: E!aP..':et Tye e Pya�-D E. �z ,c ��n� "C, Xloc Q
Thic;cress (inc`..s` 13" Tr:e ^ =: ^sistar:c (R '�luC) IZ-S%
Loo.c Fill Type `CC,�� Er-nd �/l 00�tl i -a—<,
Contractor's rni- installed weight/f:- lb '.1ickr,::ss iD_ -7 inches
Manufacturer's in<stalled weight per square foot to ac5:�-vc T;.c.—mal Resist--ce (R-Veluc)
3. EXTERIOR WALL
A.
Material j� Bra -rid 'N c Un Aq ( (c-)
_
Thickn-css (inches) �D _ Thermsl Resistance (R-Valuc)
B . Exterior LL)G � o
Material P 3tzr.d `M- c Ln-(-A-LL
Thickness (inchf:s) S7-5 Tier" a: Resistance (R -Value) - 1�
R-AISFD FLOOR
Thic'.cncss (inch. -s) _
SLAB FLOORRERiMETER
N.at�riel
Thickness (inches) _
I :._....3i :::sistar.c (R-Valuc) — —
B znc Name
Tl;cemnal Resistant: (R -Value)
Perir' c:er Insulaticn Dcpth.(mches)
FOU\D.-.TIO\ V ALL.
Ka:e:ial B. -a Na -c
Thickness (Inches) Tr.e r a. Res:s:a.:ce (R-V3lue)
Declaration
I 1Cr:-j Ccr ;f' tha! L.. 3ti ��'C IrSul3hon w15Ii:5:3i1ed L*1 3: _._ _CJ'._ .(]C3:i0n in eonf-mla.1e: W!!5 i.`:e
Enecg:: Ej-tC ene�Seor•a.ra CJr residential buildi .,es (T itl_ 2,, Pa- 5, C-,'.i'Cr ria Coi: o.`Reg`_ladens) as indica�t-•d c.-1tht
Cc:'iti_at: of Co, a plit3Sle.
I ' ,3 // (�S
Dan-a:1: S' `:cnzac'or (Co. Nanc) OR
Gc ;:raI Cor.;�c:or (Co. A3me) OR 0+ rr.
A
:a! rc, D a t c 1; .a11ing Su` -onc-actor (Co. \anc) OR
C r,!rac;or (Co. Name) OR Owner
S:`c,;n-- ctor (Co. Narc) OR
Cc -a2! Cc, -.t. ",:!Or (Co. \a,;,c) OR Owr r
A -3d
Standard Notice of Work Completed and Not Completed =
NOTICE - All reccommedations may not have been completed. See below- Recommemedations not completed.This form is prescribled by the Structural Pest =
Control Board, with whom a copy must be filed by license within 5 days after completion of work under contract.
THIS IS A NOTICE OF COMPLETION ONLY, NOT AN INSPECTION REPORT
ADDRESS OF BLDG STREET CITY: DATE OF'COMPLETION
PROPERTYLa Qu
79-866 Mira Flores Blvd CO.CODEinta CA 92253 10/15/2002
INSPECTED:. 33
FARMER TERMITE CONTROL AFFIX STAMP TO
P:O. BOX 5155 � • BOARD COPY ONLY
BELLFLOWER CA 90706
(888) 340 -BUGS (562)920-7571
FIRM LICENSE NUMBER PR1401 COMPLETION STAMP NUMBER
Notice of completion -
Sent To and date : 03/13/2003 .
Owner's Name and Address:
Copies sent to
This is to certify that the folowing recommendations on the above designated property, as outlined.in STANDARD INSPECTION REPORT NO
date: / / REGISTRATION STAMP NO: have
been and/or"have not been completed.
Recommendations completed that are in accordance with Structural Pest Control, Board's rules and Regulations:
w
Recommendations completed that are considered secondary measures under section, 1992 of Structural Pest Control Board's rules and Regulations:
Cost: $ 7(1.00
Inspection fee : $ 0.00
Others : $ 0.00.
Total: $ -70.00
Recommendations not completed by this firm
-
Signature
If you have questions regarding the work as outlined above,you should first contact the licensee noied above. Id satisfaction is not obtain you may contact
the Structural Pest Control Board at
Los Angeles - 213-620-2255
Sacramento - 916-920-5323
You are entitled to obtain copies of all reports and completion notices on this property filed with the Board during the preceding two years upon
payment of a $2.00 search fee to : The Structural Pest Control Board , 1422 Howe Ave.,Ste. 3, Sacramento,Califomia 95825-3280.
AT20:3920030313
Cit o-f La Quanta
..
Building and Safety Depar' ent
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 following:
BUILDING ADDRESS: 79-866 MIRAFLORES. BOULEVARD U=65'
Use Classification: SINGLE FAMILY ATTACHED Bldg. Permit No.:
0203-293
Occupancy Group: -R-3 Type of Construction: VN Land Use Zone:
CR
Owner of Building: MIRAFLORES, LP Address: 74-760 HIGHWAY 111 #200
City: INDIAN WELLS, '
CA 92210
By: STEVE TRAXEL
-!b Date: 04-30-2003
Building Official
l POST IN A CONSPICUOUS PLACE