9912-137 (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
Date Signature of Contractor Vf j
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
p ormance of the work for which this permit is issued.
( 1 have and will maintain workers' compensation insurance, as required by
S ctl n 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:
Cartier Policy No.
:; a°ri�:'t.Mt 1*2149 5y -
(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 ofection 3700 of the Labor
Code, I sh II fo w•th comply with those rovislon�s.
Date: Applicant—
Warning:
pplicant '^ t��
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.
Signature (Owner/Agent) Date
PERMIT�#C�I+G'i
BUILDING PERMIT
DATE VALUATION LOT TRACT
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JOB SITEt
APN.
ADDRESS 6-A6&O r'NAP/vVii WJVY,
SP!'r0az
OWNER
CONTRACTOR / DESIGNER / EyNGINEJER
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RECEIPT
DATE' ( ) ° j '
BY E
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs {
Underground Ducts
Forms & Footings i
Ducts
Slab Grade Z.—Z—&-o
Return Air
Steel I
Combustion Air
Roof Deck f
O.K. to Wrap { %
Exhaust Fans
F.A.U.
Framing J
Insulation 251
Compressor
Vents
Fireplace P.L. {
Grills
Fireplace T.O. i
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall {
Exterior Lath
Drywall - Int. Lath { Ky
l
Final
_
Final i � �--D�tJ
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings !
Main Drain
Bond Beam f
Approval to Cover
I
Equipment Location
Underground Electric
{
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
s
Gas Test
Electric Final
Waste Lines g� _
Water Piping /
Heater Final
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral !
Pool Cover
Sewer Connection { _
Encapsulation
Gas Piping I
Gas Test
Appliances {
r
Final
f
r
Final )
Utility Notice (Gas) ',
ELECTRICAL APPROVALS
z
Temp. Power Pole t
Underground Conduit
Rough Wiring r
Low Vokage Wiring
Fbdures
Main Service {
Sub Panels [
Exterior Receptacles
•G.F.I. i
Smoke Detectors
Temp.'Use of Power
i •
Final
Utility Notice (Perm)
COMMENTS:
:SUN -23-2000 2140 lJl STERhi INSULATICIN 909 686 8766 P.24/25
1V-r.r5'CERN INSULATION, INC.
4211 Latham Gt=ut, Rfvcraidc, CiVornia 92501
TeL (909) 686-8760 PaK (949) 686-8786
INSULATION C"EPI PTIFICATE
THIS IS TO CERTIFY THAT INSULATION HAS BEEN INSTALLED IN CONFORMANCE WITH
THE CURRENT ENERGY REGULATION, CALIFORNIA ADMINISTRATIVE COLE, TITLE 24,
STATE OF CALIFORNIA, IN THE BUILDING LOCATED AT:
TRACT / PHASE: BELLA VISTA 'TRACT # 28457.1
LOT# 26
SITE ADDRESS: 78-640 NAPLES DRIVE.
------J -
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ERIOR
EXl-
MANUFACTURER: Johns -Manville THICKNESS: 3 518' R -VALUE: R-13
011-INGS: BAITS BLOW
MANUFACTURER: Johns- anviVe THICKNESS; 1 UE: R-38
CEILINGS: BATTS (�_�_
MANUFACTURER: Greenstons T:11CKNEiSS: 10.3"VALUE: R-38
GENERA!. CONTRACTOR: TR;DITIONAL BUILDING
LICENSE NUMBER:
BY:
TITLE:
DATE:
INS LATI-0 I CONTRACTOR: WE.STERN INSULATION, INC
LICENSE NUMBER: 481278
BY: '� ✓7
TITLE: PRODUC:TI MANAGER
DATE JUNE 2;1,20100 e