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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 S�'f& -P-2- Signature of Contractor i r es A9 v`
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).
(. ) 1, as owner of the property, am exclusively 'contracting with licensed
contractors to construct ,they 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 q3J �1 , FkN Policy No.
(This section need not be completed if the permit valuation is for $100.00 or less).
(,V)' I certify that in the performance of the work for which this permit is issued,
I'shall not employ any persbn 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:;.meq Applicant—
Warning:
pplicant 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; ifs 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.
Si nature (Owner/Agent)"'01 Po: Date
BUILDING PERMIT PERMIT# f.
DATE VALUATION LOT l 2&,-2", TRACT
JOB SITE
APN
ADDRESS 79-M b.M. ATFLORES ROU.,Qe9ikY&RD
OWNER
CONTRACTOR / DESIGNER / ENGINEER ,
78-600 IRC1HWAX 311
:tls3D•XAI4 WILS C:A. 92210
1A Q17W.rA 92253 :.
'21 ,
USE OF PERMIT
ay±1`$012 YAM::`' XMCI
VA ii,!?C5. 3 13%fl'D""%i� 18 . 1�>r *4ZT 0r7E�,rS NOT N OXY
§0014 OPA6 'DL' 00. Wm -,1,i% OR D1U`47 EVAY .PPROACH 75% 99DUi'!"► ION ,
1"AACT CON,87Ri CTIO N F
RMIMITIM VIM OF COM MCf ion
bVT summ"RIt
ct71d"mc-1,10N ,ij"d 103.00.418.000 $313,00
.51
PLANeeE�CgyYHIEC°gdK�'99Et)W�v
94.101-OAi/C�9pC�439-318 0.r"rn
.R6EC£7�Ttdt17IC AL. FRE 101 a,POO-421-000
XL ?�TTRIC;,A1, FEE 101 -OW -420-000
PLUMBING ME 101.000.439.000 043,50
SiRt,•iND MO1' YN FEE- RE&D 1.01--000-243-000 $3.110
DIMMMER MPAC:'i' FES 1, 61.01 00
SIM •-s .cia�r�.�� r0 AM P,1 CM M
$2,t.
IMS PRE-PATD.T. MIS
$0100
•
MAY U 6 2002
CITYOFLAQUINTA
FINANCEDEP�
RECEIPT
DATEt
BY t ''
DATEJINALEV
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
— —
Ducts
Slab Grade
Return Air
Steel
— Z
Combustion Air
Roof Deck
Z40 • .JZ
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
—y Z ,o Z g
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
1.ZI
Drywall - Int. Lath
(. 6,a Z 37
Final
Final 6 3
BLOCKWAI-V APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
_ _
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) .v
COMMENTS:
I
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INSULATION CERTIFICATE IC -1
zz ;,, c. A r -n s
Peril: Numb2r
L c!
Description. of Installation
I. ROOF
Thickrt-si (incl-cs) T'I-: c
2. CEILING
N a m
Bat- or Elankv Type P-, c
Thic'kx.css (inCL,S\ a> T�-- F -sislar.c.- (:%-alu c)
Loosc Fill Type A
Contractor's rniinstalled wcIghYf:-' Ib
13nufacturces installed weight per square foot to ?ch. -,c T,=mal Resistance (R-VAI,.C)
3. EXTERIOR WALL
A.
Material s
Brand.N--c UJO mac) 0-
Thickncss (inches)
Thermal Resistance (R -Value)
13 Exterior (A-)CLeW
.
.
I'Vaterial
B r?.-. d N acnn
Thickness (inchts)
Ti(R-Value) V12
KAISED FLOOR
.
Mmeri!,
ii:_.._ N -,z
Thickncss (inc`,-.$)
-s:scanct (R-Val-uc)
SLAB FLOORj'?-'z.RIMETER
Material
Banc d. N, a .-I e
Tbickncss (Inches)
T*-;c,--ai,P,-zsls-,arce(�-%Ialue)
Pcrfmc!c: Insulaticn Dcpt!--,, (mches)-
FOUND.ITION ViALL,
N a:-
Thickncss (inches)
T*. -z=.-1; Resistance CR-Valuc)
Declaration
I '-:r:-,y c : r..,; r" t h 3! 1,-.;: 3'-10 v-: 1nsu 13 11 c r. `.gas i r, s! a I Ln ?h:: 'C a a-,2 ! o c a:: 0 n �.-, ccnf., I a n 2 w the cur-....
frerg:.- Ej-tcief; S for rcsid-Mlial buildings (Tiilz 2-,
?2:-. •Ca!'.'cmia Cod: of'?,--gula�cn;) as indicai--d On the
C C:' i aI c r C o'... a,e., -
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Si,- D
Cer,cral Cor.: mnor (Co. Name) OR Ownc:
e, D a: c
S: z 11 i r. g S eb z o n --3 c i o r (Co. Name), OR
Czn:ral Ccr.?rzcw (Co.;name) OR Own -r
S!
Sul--co=wor (Co. Na rno) OR
Cc,-.t.,zt3i, (Co. Nan,-) OR Owner
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 79-826 Mira Flores Blvd La Quinta CA 92253
INSPECTED: CO. CODE 33 09/04/2002
FARMER TERMITE CONTROL N AFFIX STAMP TO
P.O. BOX 5155 BOARD COPY ONLY
BELLFLOWER CA 90706
(888) 340 -BUGS (562) 920-7571
FIRM LICENSE NUMBER' PR 1401 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 ofitlined 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:
Recommendations not completed by this firm
Cost: $ 70.00 '
Inspection fee i $ 0.00 _
Others : $ 0.00
Total : $ 70.00
.' Estimated Cost: $
Remarks
A soil pre-treatment was performed on this property.in accordance with Stru .tural Pest Control Board r lZi lationc
Jt
N Signature
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 : -0
4 • .
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,California 95825-3280.
AT21:1520030313
Certificate of. Occupancy- ,
City of La Quinta
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 regidating building construction or use. For the following:
BUILDING ADDRESS: 797826 MIRAFLORES BOULEVARD U-70
Use Classification: SINGLE FAMILY ATTACHED Bldg. Permit No.: 0203-298
Occupancy Group: R-3 Type of Construction: 'VN Land Use Zone: CR
Owner of Building; MIRAFLORES, LP Address: 74-760 HIGHWAY 1.11 #200
City: INDIAN WELLS, CA 92210
F
By: STEVE TRAXEL
d Date: 04-30-2003
Building Official
POST IN A CONSPICUOUS PLACE
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