9912-079 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I amjlicensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full forcefand effect.
License # Lic. Class J Exp. Date
�`� 7:394115 ks r a2i'Z;�i
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).
( ) 1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code). I • •
( ) I am exempt under Section B&RC. 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
pe ormance of the work for which this permit is issued.
I have and will maintain workers', compensation insurance, as required by
Secii6n 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.
STA.'} FUND a6a5355."S
(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 fo hwith comply with those provisions. (�
Date: Applicant I! • _y
— v
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
Signature (Owner/Agent) " 1+ Date w ti
BUILDING PERMIT PERMIT#
DATE !! VALUATION4eD.� .i. LOT 211 TRACT 294%1-3JOB
;
SITE
ADDRESS ` 78-505 l,iiiTLIS DRIVE
APN 609-13711-038
OWNER
CONTRACTOR/DESIGNER/ENGINEER
?1#� AA?CE13 �I7 Vlil, i'11Li1;?Na" C'.(J:RP
` II A:I'IJT DNIk.L SUIT ,IMGs CO NIC
7£=615 NAPUS DRME''
78615 NAPLES DR
1—A, C;,►19 NIA CA. 92253'
LA Qt1i1+J"i'A CA. 92253
(76t))772-022? C}3(A 5750
USE OF PERMIT,
Sttvvl..I TAMII Y DWELI:N p
M.) .)41LAh .3AR,,Lt:J.1A2i..i',CJad E; 00 lit -11 INCL 0DE BL0CK WJ ,I..5.OR
POOLY LAN 0 .!~CK AJC Y ti.Fit (X T) BY 75% FO.K INIVi,1`Ix LE ISSUANCE O
SAME PLAN 'C%TF.
TACT i"CiiJTI(vCTLC)N G,065."VV :it
PORC:M5.1MO 32.00 SI`
(1, k R AG IV CAIU.'0tZ C 439.00 'Z'
PERMIT VET SUMMARY
OG1481CR IGIAOt FEZ 1101-000418,00 $709."
a/yN) CHECK H`1I"s Jot-/��►((��(1-4�59./3!f $146,93
apt[.
(-J11':!.✓C1&%1VC1114 �'`3 J�J�-VVV-'�•74I"`UVV 3'JZ. JV
111LEC RI[CALi;UE 3.01--000-420-i>CO Si28.i.6
-
PLUM13fNG Lim 1011 -000 -439 -OW $140.75
3TRONi.'iv.0410-7N l+f ,- RESIT) !(11-W..24t-(100 Si1.93
CIVIUDI -TO ME 1011-t}W-423-000 $20.010
NFRAS7Y UCT URE Iasi, 225 -CM -443-34:2 51.907,00
/SWC 1N PUBLIC PLACES - RES11; 701-000-25�5-000 $48.1:3
i
t
StIK•TOT.�L CONS'i'i�t.1CTIc1;V .A`N1 f P; AN CHECK
$3,itii,9ti
` ;i,,.CS`a 1'1;:Y:f>M(. FEES
$0.00
't"Cy'Y'AL PERM VC FEES DUE `il NOW
$3.10.95
, 'm
RECEIPT `
DATE
BY" /
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTO
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs_
Forms & Footings
f
' 2 7J
Underground Ducts
Ducts
Slab Grade
z—Z —&0
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U. loor
Framing
�j-a
Compressor 401,
Insulation
U -v
Vents
Fireplace P.L.
Grills 0-000,
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
p
Drywall - Int. Lath
--tea
14
Final
Final
r
POOLS' -SPAS
BLOCKWA
L A PROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
I
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
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring /01
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
✓UN249
WESTERN INSULATION, INC.
4211 Latham Street, Riverside, California 92501
Tel. (909) 686-8760 Fax (909) 686-8786
INSULATION 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: BELLA VISTA TRACT # 28458-3
LOT# 21
SITE ADDRESS: 78505 NAPLES DRIVE.
------------------------------------------------------------------
EXTERIOR WALLS:
MANUFACTURER: Johns -Manville THICKNESS: 3 5/8" R -VALUE: R-13
CEILINGS: (;;;BATTS BLOW
MANUFACTURER: Johns -Manville THICKNESS: 13"VALUE: R-38
CEILINGS: BATTS OW
MANUFACTURER: Greenstone THICKNESS: . -VALUE: R-38
GENERAL CONTRACTOR: TRADITIONAL BUILDING
LICENSE NUMBER:
BY:
TITLE:
DATE:
INSULATION CONTRACTOR: WESTERN INSULATION, INC.
LICENSE NUMBER: 481278
BY: oj�' P, f4UL-_
TITLE: PRODUCTON MANAGER
DATE JUNE 23,2000
c�