0012-102 (SFD)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.
�pjicense # Lic. Class Exp. Date
?
41M P,
mate D %a� Signature of Contractori�
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 solo
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 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:. 'b .
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 Policy No.-
-CIOLDEN .FAt:+ E PIS.
(This section need not be completed if the permit valuation,is for $100.00•br 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: I 14>�<"1/' APPlicant "" �' i �>> f
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000•, in
addition to the cost of compensation, damages as provided for in Section'3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building.and Safety
for a permit subject to the conditions' and- restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at',
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, inderrinifP
& hold harmless the City of La Quinta, its officers, agents and employees.'
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws, relating to. the building
construction, and hereby authorize representatives of this City to enter upon
the �above- mentioned property for inspection purposes: f ((
S' nature (Owrier/Agent) / f7 , f%i< Date
- : BUILDINGPERMIT PERMIT#
DATE VALUATION LOT f� �.t TRACT .
3.90 56
141 X
JOB SITE
ADDRESS 76-f i 2,11 ?l2.1!f� G 9YAR WAY.�
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
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Al I'my(mov-d - LL Coto t1.•C3MTIi S
IG:
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
:N•
MECHANICAL APPROVALS
Set Backs
?jam cow_
Underground Ducts
Forms & Footings
2 2$ C2� _
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
t�--VX
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
Exterior Lath
Party Wall Firewall EqVK
Drywall - Int. LathT/47/_
Final -a2 -4L gzf
BLOCKWALL APPROVALS
Final
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
Z��
Encapsulation
Gas Piping
Gas Test
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 ` 4�
Utility+ Notice (Perm)
AUG -20-2001 15:13 WESTERN INSULATION 909 686 9786 P.13/14
_ X
5;
VMSTERN INSULATION, L.P.
¢211 Latham 5tz=t, 9 remide, Ca fomis 92501
Tel. (909) 686-8760 Fax (909) 686.8786
INSUI ATION CERTIFICATE
THIS IS TO CERTIFY THAT INSULATION HAS BEEN INSTALLED IN CONFORMANCE WITH
THE CURRENT ENERGY REGULATION, CALIFORNIA ADMINISTRATIVE CODE, TITLE 24,
STATE OF CALIFORNIA, IN THE BUILDING LOCATED AT:
TRACT / PHASE: STARLIGHT DUNES #23773.5/PHASE 5
LOT #: 56
SITE ADDRESS; 78-845,MOMNING STAR -WAY: LA-QUINTA, CA
s
7 7
EXTERIOR WALL$
MANUFACTURER: JOHNSMANVILLIF THICKNESS: 3 5/8 " Ft -VALUE: R•13
CEILINGS: BATTS BLOW.
MANUFACTURER: UREENSTONE THICKNESS: 10.3 " R -VALUE: R-38
CEIUNG§n BATTS BLOW
MANUFACTURER: JOHNS MANVILLE THICKNESS: ' 131, R -VALUE: R-38
GENERAL _ ONTRACT01 CENTURY HOMES
BY;
TITLE:
DATE:
INSULATION CONTRACTOR: WESTERN INSULATION, L.P.
LICENSE NUMBER: 794484
BY:
TITLE: PRI05 C N MANAGER
DATE AUGWST 20, 2001 ��