9912-069 (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.
License # Lic. Class Exp. Date
75M55 x3 02/291201
t`
Date '+ Signature of Contractor 7
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 Policy No.
STATS F UMO `X►2d3�a3-'
(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 p ovi ion
Date: 'AWICIS Applicant
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 in pection purposes. ��r
Signature (Owner/Agent) Date ,- 1L� 9 `
BUILDING PERMIT PERMIT#
9y 12-069
DATE VALUATION $141.248.40 LOT `� TRACT 21:454 3
ICIJOB
-/I A
SITE
ADDRESS 73-665 NAPLES DRIVE;
APN 609-1070.638
OWNER
CONTRACTOR / DESIGNER / ENGINEER
78-6i,5 NAPLES i+UR
78615 NAPLES R.
LA QUtNTA C;:A, 92253
LA QIUINI',A CA. 92253
t100)77'2-0222 031At 57 -SO
USE OF PERMIT
StNGLE P.M/fiLY MEW NG
Sn-1 4 L'.AN .-XW,L0T#1 i.? tii IT DOES 140T INCLL:u>iz isi.i-i K N6'ALL9 OR
P0Q1_P1,A.N (_1ffikX 1,7K8f8-REOUCM) Wi' 750,4 FOR NIUL '1'IPL)i ISSUANCE, O
SAME LAN TYPia
.M, .. .-M..,014 +i 400.M 3F
1101i(s'.IrrPATI'O 160.00 SP
tJARAQsVXAt 1,10ft1.' 419,00 SF
E5,1 PIGITED COST OF i:ONSTRIJCIPION
3.41,24SA0
>k MOT C%Tf SUMMARY
t,oNS"I"It.E;G°noN a.t~s 101-000-4 is -M) rM6.50
PI. -A-14 <Y4F("K F Fr,, 1.01-044-419_. i i q $ i 61.98
M.'31CHAINICA;.. VEF 101-;11M.421.-404 U0,00
1 f EC' I'RICAL. V' .E. iG f -000-4.20.000 S i4 k.:18
PLCINlksfNG FFH 101-000-419-000 5140.75
e'r'!t0NO M, (Yri(,)N F92, - RE'SK0 1 n t -000-241-000
CRA IG F 0L 101-000-423-040 520.00
L&VEL OPE t INIPACT T- 11.9o.00
ART .1N PUBLIC PLA.CM - RH5X' 701-000-255-000 S103A2
$C;t NS7"RL:r710N NI T) PLAN `'iM X
$.3,334 Qr,
L.E.-S.. PRI -.('.MD FEES
$0,00
`IrC)'l'ta1_,, PERMIT FKOS DUENOW
$3,334.95
RECEIPT
DATE ,
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
!� _ (
7 !�-
Underground Ducts
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
—
F.A.U.
Framing
Compressor OF
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
�® p
14-00,
Drywall - Int. Lath
Final
Final
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 I
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
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 2 �d
Utility Notice (Perm)
COMMENTS:
'rUN-23-2000 11:34 WESTERN INSULATION 909 696 B766 P.1225
Fr �
1.
INE8'rERN INISU LATIONr INC,
4211 Latham Street, RNM ide, California 92501
Tel. (909) 686-87i5o 'Fax (4.D9) 686-8785
INSILATI®11� I :j:F:TIFICATE
THIS IS TO CERTIFY THAT INSULATION HAS BEE -IV INSTALLED IN CONFORMANCE WITH
THE CURRENT I:NERGY REGULATION, CALIFOPNI.A ADMINISTRATIVE CODE, TITLE 24,
STATE OF CALIFORNIA, IN THE BUILDING LOCATED AT:
TRACT i PHASE:
BELLA VISTA TPukC'T # 284.58-3
LOT#
11
SITE ADDRESS:
..............................
78605 NIPPLES DRIVE.
EX1rER10RUVALLS•
MANUFACTURER:
Johns-ManvilleTHICKNE,S: 3 518" R -VALUE: R-13
Cil GS:
SATTS BLOW
MANUFACTURER:
Johns -Manville THICKNESS! 13"VALUE: R-38
ElIJNGS;
BAITS , BLOW
MANUFACTURER:
Greenstone TIICKNFSS: 10.3"VALUE: R-38
----•------------ -----------
_QENEi_�4L GQ C.T®R: TRADITIONAL, BUILDING -
LICENSE NUMBER:
;
BY:
TITLE:
DATE:
IS T10G`C NTRACTIOR: W -z- iTERN INSULATION, INC.
LICENSE NUMBER: 481278
, Lfb�
BY: 1 1, ujo
TITLE: PROD BON MANAGER
DATE JUNE 20,,2000