SFD (0203-296)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
B C8 IRO
Date 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).
() 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:.
Cartier S f,ATH F014D Policy No. 1603611,02
(This section need not be completed if the permit valuation is for $100.00 or less).
(�4.!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' compensationsprovisions of Section 3700 of the Labor
Code, I shall forthwith comply withfthose provisions.
Date:Applicant—
Warning:
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 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.
� I f
S" tOwner/A —M, %� a��, Date
Igna ure ( g
PERMIT#
BUILDING
.PERMIT
DATE VALUATION LOTTRACT
JOB SITE
APN`
ADDRESS '%9 s7. jf. IRAP'LOyg�+ i nIr3�.i'r IMA
{y
'` .T'-�Sg`' .•- � "I
OWNER
CONTRACTOR/DESIGNER/EN INEER
:S, 'Lp .
1xv. 1��:v , :tl* c &a DY- T £:iii F17S DEV14-760
M1G1q%74' YI 110200
8.60% F11C�&'iWAY 111
1�.i
��1J.>AM M .I.S CLQ. 92210
7 �.��J�'T6� CA 92,253
M.R.2180
USE OF PERMIT
p ► pyq �fi p 7� �}y�q�.
�➢S.LY'+7,A�I�.S'`!"lFtiLkr 31, �`1%-.SJ�.�r1.i.S:�,7..�
SPA - }�,I0034, DANT 6 y PLAN 28 . l�� 1241 ' 1)OHS 14a?'f"1NCL9:;,DE
P001,8. U.i�)Ck W OR !�#il'4�'►;'��:t�`si' .�a:F�'�:t�.�f 04, 7ML,54I�l�MIC'�`ICLN,
114 PLAN' Cf�i f^:1 PFZ FOR M131 fIP1..0 I3SUAN E OF.`1,�A;§E P1.". 7YPLI.
`TRACT CO?�w�i'13.UCT1014 B9a,r� 41,11—e1r'�I'lill�AlED
0091' 0:1+''wt�.�7S�'�Tl�(:'°1+T�C91ti!'
CC;NS'1RUC�"i034 FEE 101>060,4188 4;10 da .f>i3
PLAN B:tfJWX 1;•E1; 101-000-4 9-319
IidSICHA�71r,F L Ff 101.000-421.-i ii
.Lr-LWFF. F, 101-000-420-000
PLiUMBINO IEE 101.000.419.000 M00STr.�.c�N'OMOTIQTF�f�@?E
RMID 1, 01w-00O.:?43.000 �A.GC
dal's`� &L�O:'Ts'.It HAPAC T ME
gb
1X3. PRF --P '
$0.00
`S14AY U 6 2002 'AL P'�',��.' FEES DUE NOW
CITY OF IAAUINTA
FINANCEDEPT s.
RECEIPT
DATE
9V .: 14. t
D T ALED
INSPECTOR
r
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
—
Underground Ducts
Forms & Footings
9_9_2
Ducts
Slab Grade
Return Air
Steel
— — Z
Combustion Air
Roof Deck
. o y 7
Exhaust Fans
O.K. to Wrap
, o y g 7
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
ri d Z
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
. sc o i ST
Drywall - Int. Lath
2 -XI-42 a✓ 27
Final
Final
BLOCKWALL
CL3 5
A PROVALS
POOLS - SPAS
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
_(( 10 9
Encapsulation
Gas Piping
Gas Test
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
Utility Notice (Perm) 03
COMMENTS:
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
PROPERTY- 79-842 Mira Flores Blvd La Quinta CA 92253 09/08/2002
INSPECTED: CO.CODE 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 I 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:
Recommendations completed that are considered secondary measures under section 1992 of Structural Pest Control Board's rules and Regulations:
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5 Ll
INSULATION CER-nFICATE IC -1
Sit,, Ad•'ress PrrrnI: lumbo
Description of Installation
1. ROO;
in
Thic:�nCss (ir.c .es} j `r T;:cr_: Rcsis:�nce (? Va!ue) 3
2. CEILING Uri
-
Bat' or E!anket Tyre �"7. P.='— Namc ����X\� ri .n ou(
Thickncss (inc'-s' 3" The=a. F6sistar.ce ( A'aluc)
Loose Fill Type Brand
Contractor's rni installed weight/P-' _lb tiickricSS ? inches n
IManufacturces installed weight per square foot to ach:evc Tr c.—mal Resist-- ce (R -Vel :e)
3. EXTERIOR WALL
A.
Materials
Brand \a- c a A l�l� UJD A-1 [) t 0- _
Thick css (inches) — Trermal Resistance (R -Value)
B . Exterior t,uCLAO
Material ?Ylt+5 3tzr.d Na^e t�
Thickness (inches) S-70--- T e.,.,a: Resista-c: (R-V31t:e)
RAISED FLOOR
Thic'.cncss (inc`--s) _
SLAB FLOORYHRIMETER
Iv'atcrisl
Thic%ncss (inches)
Pcrimvc: Inst:lat-icn, Dcpth (inches)
FOU\ D. -.TION' V ALL
Iv1.ate:ial E -a -a N :
Thickness (inches) T'.e:r..a' Resis'a-ce (%-Vslue;
Declaration
1 :hcrecy cer.if that irsular,er. was ins'31l_d in the c_:':c.-.4 3.. ._ s`o•.: oca:icn cc; r` -aa ;cc wit` Lye ccrr.r..
Energy E icie�e� Secy'.:. for residenti3l buildi .Ss (Titl= 2,, Pa' 5, Ca'i:
!Certificate of Occupancy
City of La Q.uinta
Building and Safety Department
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: 79-842 MIRAFLO.RES BOULEVARD U-68
Use Classification: SINGLE FAMILY ATTACHED Bldg. Permit No.: 0203-296
Occupancy Group: R-3 Type of Construction: VN Land Use Zone: CR
Owner of Building- MIRAFLORES, LP. Address: 74-760 HIGHWAY 111 #200
Building Official
City: INDIAN WELLS, CA: 92210
By: STEVE TRAXEL
Date: 04-30-2003
POST IN A CONSPICUOUS PLACE
j