SFD (0203-300)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 4— 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:.
Carrier STAT { VU14D Policy No. 1603614.0
(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 shall forthwith comply with those provisions:
Date: Applicant ? #�•�a
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000,.in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for permit subject to the conditions and restrictions set forth on his
application.
1.'Each person upon whose behalf this application is made & each person ail'.'
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify:=
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is I
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon R
the above-mentioned property for inspection purposes.
1 ,1
Signature (Owner/Agent) �f t % __ Date'
f s�.
BUILDING PERMIT PERMIT II
DATE VALUATION LOT. ° 7 "TRACT
Aj7-. r , '; :? W,435.60 B:3$ 1721 28691
JOB SITE
ADDRESS 79•.8 ,0OR"W��IES 1301)UVARD
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
MIT) DEV., INC dba DEMRr MIMI DEV.
74.7€01'3 OPI-TWA11 0200
78-6001H0T1'd PY— I I I
DMIA V=e is CSA 92210
1AQ!LlWA. Cly 92253
ai
(760)771 w 3 34,g CBVt 14180
USE OF PERMIT
., A o r�i,D 3b,'UNIT' 73, }? AN 3kt. 1: ERMIT DOES NOT 1.AiC&JlI�L �
POOL, SPAT, sA, Z,OC14..WALLS, OR DIUVEWAVA6PPROAC H, 4t°Jo.1 RDLIC'i ION t
IN P.T.Al'i t`I£1=X- rKR FOR. f+FitLT1F';(.E Y"St)AN3 CF Ole WAE MAN TYPE,
`t RAC T C0NSTRUCT1C'tR . 393.0@ SP
PW`al AM. .) Con (3r Cong:MucIc't'Cqn
PERMIT FEE SUMMARY
CorNSTIRUctTION FFI 1t13�E?t O I aC3t1D ��( .�
PLAN C1.1F;CK FEE 101-�aC1� 4-318 $9i.6;t
MECHA141e'AL FEE, 101 X000.421.000
ELECTRICAL i?fP 1 ioz-000.4o-000
PUFUSINO PF'R 101-000.419400 U&SO
STRONG MO- IO'kI FE1. - MID 101-000-2161-000 �4.34
1JzVnCap1!:R IMPACT FC+',,$ s'6,$ia fto
A1PI.EICWLC
?KE-FAA
17
$0.00
RGES LAAs
U 6 2092 _
` . .
CffYOFLAQUINTA -
FINANCEDEPT
RECEIPT.'
DATE i
BY
IDATEtINALED
INSPECTOR
r
' 1.
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms &Footings
-B
Ducts
Slab Grade
—
Return Air
Steel
e Z
Combustion Air
Roof Deck
G •,iy- v v g 7
Exhaust Fans
O.K. to Wrap
F.A.U.
FramingCompressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
( • .z 6 , 0 2 37
Drywall - Int. Lath
(• 't, L •� i s
Final
Final 03EE
BLOCKWALL APPROVALS
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
/ • O 3 s
Encapsulation
Gas Piping
Gas Test
( �j
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)
INSULATION CERTIFICATE IC -1
Site Addr_-'ss
Description of Installation
Nt-r-d- Number
L c: �:_...._
1. ROOF
Thickness (inch'cs) N 3 " Resis:ante (R-Va!ue) 3�
2. CEILING
Ba;' o: E!anket Ty pc vlyJd5 P- a:-. '- \ am C --Zkn�rt Xl I �d L 0
Thickr.ess (inc`.:s` �3" Tie ^ =: sis;ar:ce (R 'aloe) ��
Loo.c Fill Type �c i� Brandt /I DO:t'l iJSil
Contractor's r::i- irstalled weigh /f:= /r _lb IN4inir^._.n t kness ? inches
Manufacturer's irstalled weight per square foot to? c h .* e ve Th c, -mal Resistance (R -Value)
3. EXTERIOR WALL
A.
Material Br2u d Na -c UJ0 A-1 C 0. _
Thickness (inchcs) 61q- Thermal Resistance (R-Valuc)
B . Exterior u -)G. O
Vaterial ?-)LtkS 3rzr.d NL :e
Tcicicrress (inches) 3' Ter aI Resistance (R -Value)
R-?ISED FLOOR
Material _ B.ar.1 N_.a._
TI,iC:CireSJ (InC :5)! t.C....11 cs:srar.c: (R -Valu--) —
SLAB FLOOIL'PERPMETER
Mat -_•tial N -,me
Thic'kricss (inches) T, er.mal Resistance (R -Value) _
P'crir..c;cr Insula -ti ri-Dei h (ir thea)
FOUND. -.TION NVALL
Nj.atc.ial R-an-� N2: -c
T:;ic'kress (inchcs) T"e.r..a! R.:sis:ance CR-Valuc)
Declaration
I'acr-,"Y c2raf; that l:.0 31-10vc ir5sulvich %vas ins,311Cd Ln t1'._ C_:1=: -.t 3: 2b3-._ !CCa:iCn 11 COnfC—MI n.e Wrth LS: CL•M—
Er,erg.7: E_%Kiencz Sfor restdential buildings (Title 2-:, =a- 5, Ca':i:cri3 Comae o,`Rcgula ens) as indicatL.d ca the
Cc i:t_3t� e` Comp!ia c , u -_.c a; p!icable.
SS De_.. 1-,:a.ti 4Lb:entr3c;0r (Co. Nanc) OR
• G� :cal Cor.;�:ror (Co. 1:ane) OR O•+.•n::
I:c.n a: re, D;c 1- .211ir:2, Scb:ontrauor (Co..\arc) OR
Gc-::al Ccr.tr2e:or (Co.. lame) OR Owntr
Subcor.c:-ictor (Co. Name) OR
Cc-:! Ccr.rra:tor (Co. tiane) OR Oµnrr
C=. -c „tries 5.
Standard Notice of Work Completed and Not Completed
NOTICE - All reccommedationsmay 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
PROPERTY79-810 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 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: ,
y
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 -
t
Estimated Cost: $
Remarks
A soil pre-treatment was perfo aperty in accordance with the Stm .tural Peqt Control Roard
w
Signature c �;
t
• If you have questions regarding the work as outlined above,you should first contact the licensee noted above Id satisfaction is not obtain, you may contact ,
the Structural Pest Control Board at : t:
Los Angeles - 213-620-2255
Sacramento - 916-920-5323 r
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.
i{•: AT21:1420030313,
Certificate of Occupancy.
CitY of La Quinta
Building and Safety Department OFTM
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: 79-810 MIRAFLORES
BOULEVARD U-72
Use Classification:
SINGLE FAMILY ATTACHED
Bldg. Permit No.:
0203-300
Occupancy Group:
R-3 Type of Construction: VN
Land Use Zone:.
CR
Owner of Building: MIRAFLORES, LP
Building Official
Address: 74-760 HIGHWAY 111 #200
City: INDIAN WELLS, CA 92210
By: STEVE TRAXEL
Date: 04-30-2003
1 POST IN A CONSPICUOUS PLACE
l