SFD (0203-299)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
Date e2f 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 4o construct the project (Sec.. 7044, Business & Professionals
Code). `4 ,
O I am exempt under Section B&P.C. for this reason ,
Date—Signature of Owner
FV
'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 8TX!°EE�'lJNiJ Policy No. 1wD3416 43
(This section need not be completed if the permit valuation is for $100.00 or less).
(h°) I certify that in the performance of the work for which this permit is issued,
I st.iall 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'thdse provisions.
Date: *,-J' � d5 `+r.. Applicant ; �, 4;1W, i f, A,
Warning: Failure to secure Workerf 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 4
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 form{spection /purposes.
Si nature (Owner/A ent) '
�� .fd' t.�! Date
PERMIT #
BUILDING PERMIT •'
DATE VALUATION LOT" TRACT
JOB SITE �
ADDRESS i�b•Td�Lka GfV Yr�A9dsLii,T}r,�
APW.
Q,i3°E.S
OWNER
CONTRACTOR/DESIGNER/ENGINEER
LMMAiYLORrO, U?
DCD MEN, INC dba DES 'E�ZT C-rf1rA :&eV .
74.760 Y -1101A AY l 11 0400
78-600 MONVAT I 13,
INDIM WIMT-A
LAQf:I'i 1TA CA 9
(7760YY?1-3:345 CSIX 21 so
USE O��F�pPERMIT
gp F N Xr y to CH,
TO
SEA - Iii DG,. %i UNIT t, p1,40 28 . FZRIA17i DOPE NOT INCYAf, OM
P004 SP A.,8100'lc WALL% On. 0.1p i rWhYY APMOP.,t;11', -6%. S?,DUC'fr1(J.4
r`
'I'luACT f:ONSTRIXTIf, N
Esm"(;;02TT 01? C ON S°d`I,''k7�C':TTD.N
40.435.60
CONST RIUM ON FEE 101-000-418-000 949,00
FIAN CHECK FEE 101-,000-439-91 I5 01.61
M BCftMlCA4 FE 01 AC*0.421-(100
;g}��'LE L,,};M'�, f.J01-0�yy}P09��4� 20-P�t0r�0 rryi
@�64,
pct�T.+pl��77i�C//.tyy,,
,t".5,,*..11�J R40 MIR R 1 `V 1-000-419-000
S .T110NO A9f1'9`ION FES ; k2 aID 101-000-241-000
DEVU/0PIRM IMPACT .FEE
r
ST384WAL, C0XSt 11e..'VC3.W:AND )PLAX C"lluix,
t2,266.17
" x.3.al iY3' r.-Pfial.3 two
MAY U 6 2002
CITYORAQUINTA'
FIRANCEDEPT
S0.00
RECEIPT
DATE �
BY7' : 3 j
DAT DIALED �
INSPECTOR
2
e
1,
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs,_z
Underground Ducts
Forms & Footings
p
Ducts
Slab Grade
—
Return Air
Steel
Combustion Air
Roof Deck
•JZ_ 5z
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
W.
Final
Final c o
BLOCKWALI 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
Gas Piping
Encapsulation
Gas Test
.-% —5
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)
LI
INSULATION CER-flFICATE IC -I
Sitr Address
Perm.I Number
Description of Installation
1. ROOF
Thie<r.es_ /tr.c`cs j'
� ° ( ) � � 1%C�ia: Rcst$:ance (R-Va?Ue) 3 rl
2. CEILING
Batt o: E..an'.:et Type P-.== N -^c
Thickness(irc`.-s` t3" Ihe=z' ^sistar.c:(1 'aluc)
Loose Fill TypejE,J� Brand
Contractor's r::i- installed weigh /it' A_lb IMini _ n t' uknas lQ- inches
Manufacturces installed weight per square foot to echievc T crmial Resistance (R -Valu)
3. EXTERIOR WALL
A.��e-�i o�cs dX(o—Picwto 3
Material i6(�5 Brzrd Na -c C)L(
(
Thickness (inches) Thermal Resista-ce (R -Value)
D . Exterior i e.)CLUO
Material C SS Bard Na m.c
Thickness (inches) 3 T e.;.,ai Resistance (R -Valise) - 1
RAISED FLOOR
Mmerial _ B.ar..3 Na e
Thielvtcss (inc`.cs) Ti: a? Resistance (R -Vale)
SLAB FLOO?U?—ERIMETER
Material Bznd Name
Thickness (inches) T ermnal Resistance (R -Value)
Perimcter Insulatic.n Dcpth.(ir.ches)
FOUND. -.TIO\ \VALL
iV(.atc:ia? B:ana Na .
Thickness (inches) T .era; Resistance (-1-Value)
Declaration
I h:rCOy ccr:fy that l.',_ 317ovC Irsulation `.vai ins:311cd Ln a: _._ conf�.ma nce wllh Li:
Er,erg,- Ejlcie!:Sroc�:r1 for r:sidcntial buildi:.Ss ( T itl_ 2,, Pan 5, Cal::omla CoL'c Regal ens) ss indiea��•d on the
CC ti.lca(L Cf C0M2i:3 C , wc S. PI:cable.
Lem -s S;i2r c__, Ds:, lr.stallir. c, �.CpZ 3C,or (Co. Name) GR
/ V Cc ,:ral Ccr::mac-jr (Co. Name) OR Ownc:
Da:c
1^a:aliir.g Sub -on- 2ztor (Co. Name) OR
C- -rat Ccr,!r2czr (Co. ; amc) OR Own:r
1-5:ailir.s Sutc- c. 3c:or (Co. Nam, c) OR
Cc,._,21 Ccr. ,.._:o r (C0. N.71C) OR Owrcr
Cc- . tu- 2=v1 A•36
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 79.818 Mira Flores Blvd La Quinta CA 92253 09/11/2002
INSPECTED: COXODE 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 r
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:
Cost: $ 70-00
Inspection fee : $ 0.00
Others : $ 0.00
Total-: $ 70-00
Recommendations not completed by this firm
Estimated Cost : $
Remarks
A soil pre-treatment was peformed on this property in ner irdance with Strncfural Pest Control Board regnlations
Signature
If you have questions regarding the work as outlined above,you should fust contact the licensee noted 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, Sacrarnento,Califomia 95825-3280.
AT20:5220030313
Certificate of Occupancy
Ci.tyof La Quinta .,
Building and Safety Department
This Certificate issued pursuant to the requirements of Section 109 of the -Uniform Bui/ding 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: 79-818 MIRAFLORES BOULEVARD U-71
Use Classification:
SINGLE FAMILY ATTACHED
Bldg. Permit No.:
0203-299
Occupancy Group:
R-3 Type of Construction:
VN Land Use Zone:
CR
Owner of Building: MIRAFLORES, LP
(dam
Building Official
Address: 74-760 HIGHWAY 111 #200
City: INDIAN WELLS, CA 92210
By: STEVE T.RAXEL
Date: 04-30-2003
POST IN A CONSPICUOUS PLACE