0011-263 (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
Z714188/ i3 1, y,.1 t7l 1/2(
ate /�> ./ 4�Signature of Contractor' 91� !� { i +'�� 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.
NLA I have and will maintain workers' compensation insurance, as required by
$ ction 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 OOILDEN EA01.0INS, Policy No.
(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
/ode, I shall forthwith comply with those provisions. .,
Date f?'= %fir A licant `-- �'r7 ? Ir i -� 4 Z
PP ,. .. .
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subjectan 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 voidliff y
work is not commenced within 180 days from date of issuance of _01-1.i
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. r
/Signature (Owner/Agent)r ¢_ f i Date
BUILDING PERMIT PERMIT# ;
jjjjjj
DATE � /y VALUATION LOT 0011-26'.3 TRACT .
4 6. U019
JOB SITE
APN
ADDRESS 7"115 (1.1 1 o
7459- 19FVA,
OWNER
CONTRACTOR / DESIGNER / ENGINEER
CYN11UrRv movM11 commi7AiTi'tll a
CEWfURY C%011v�'.�,,T., COMM..C.i2+T.i.O S
35.-45 so. 'Do Srrmu, ^' 9200
1535 30. "D" hUfR ET, 5'7.'?, #2W
SAN BE C� ARD190 CA 92408'
SIM( BEMARDD40 CA 9240�
(909)381.600 CPILH 7120
USE OF PERMIT
08012 FAMUY DW E�. 1MG
Q IVY 40, PLAN :IC; 310.-9PERMIT DORS `NOT ]INCLUDE BLOCK 113KL I. S,
P0014 OR DRIVEWAY APPROACH, PLMN CHECK I SR REDUCED 'S`3% FOR
MULTIPLE ISSUANCE OF 5". 3 PLAN T'YPF
CUSTOM C0114,1TRUCT10N 2,$15.00 Sly
POIt.C"AT16, 15*7100 SP'
L'iARAOWCARPORT (SP) 9,MA0
mimam4'frror°GCAmo'it�.tncryom
231,: .
P -k: fl_-1ir`.UR RUMMARY
CONSTRUCTION FISC+, 101-000-418-000 8111411150
PLAN CHUCK FEE 101..000-439-318 $221.47
MEC'IIANIC.AL FEE 101-000-421-000 "8150
L'LWITPUC'AL t+'.EB 101 -0042a-001, $142,31
PLUMf3C1 OFEE $168.30
Si7.tONO I* OT10A1 FBI?,, • bRM3.113 M-00&.241-000 0&. 1-000 $ 3,14
GRADD40. $20,00.
DEVELOPER IMPACT FEE $1,907.00
ART 1N .1a'UBLIC PLACE' .3 - P.WSIC 701.000.253 4XIO $78,36
s-
�,a�
�.-TCZ't'Jil:(. Ci'�.1VS.C22Y.I�YCt18 7<�.13 3P�,4A1' CI"kTCK:
0 A
�3,'7f 1,7't�
'y (� 1
JEC 12 . �. LF*9e2 PIZE-PAM PUS
50,00
OFULA QUAI 'T(Yfm,.lG" MITmp30 6DVE,L 067
A
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
r OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
—67
Return Air
Steel
f
Combustion Air
Roof Deck
3=s D�
Exhaust Fans
O. K. to Wrap—
c�f _
F.A.U.
Framing
Insulation
_Zg%d
Compressor
Vents
Fireplace P.L.
/
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
_
Drywall - Int. Lath
Final
Final
_(
_�
POOL §'- PAS
BLOCKWALA
APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
I I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines—
_
Z —
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer LateralJ8�
/ .
/ (�—
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
S�
Appliances
Final
COMMENTS:
Final
'
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
100,
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
r
Cermicate of insulado'n
--- _- _ Your Rome has been insulated with Ce:tainTeedd FibmWass lasolstion yaduets. which are desigped — — ---- for Ufty's safety standards and tomanoWs eaeW requirenumb.
o-
0
tn
s
z
cc
U)
z
0
N
O
O�
m
iv
v
N
U?
O
FibmWass is inatgank and therefore parmattently noncormbustible, so it does not have to be treated
------
with chemicals tTUtt can e,arwdo wiring or metal F'hi alm will not tt mtb moisture mor wit! it — -- -. ---
---settle.ox�e�tirneas-mayo$ecimmWoomBhrial.----------...------ -- ----.... ----------
n6 also, certifm that ecrwaieed Fier Giam lErtsplutian hag been iprofemionalty-immied in ibis bomie
to provide thu followigg thermal p"irmame.,
-- ------ - — Job Nmm-. Manilarbso — - --- — trach f Zfl719 Pkn tk 3C T Phase: '-- 2 — ------ - ---
------
Ceiling Atnea• R-32B3oVm Iaselatfon GsrageCeftkg: "om.Aasess:
With Lowing Abp.. _& SWPPing Ares . _.._
Exterior Walls: 1t-13 Unfaeed Batts dive ng,►: Aecess Attic. --- -
inerier Wali: R-1 l Un aced Batts Between Floor,
SEIki:IDJtthwtkl« OJIi8d!1 &WOU Co., INC.
ft211e1rMUd%Tenmu1mCm9ZWO
Sigmea
.Toms Berms►, Gemra! ldl &h'- 7'emtecata Brmck
R- means resistance to beat flow. The higher the R- value, the greater the imulating power.
Ask your builder fear the fact sheet on R- values. Keep this certificate with your other
valued papers. if you e%w se11 this bomo, this certificate should be passed on to the buyer.
05/24/01 THU 13:22 FAY 780 7727193 JON TANDY
r V
REGISTEREQ lIM$PEC'I�OR'$ WEEKLY REPORT
@1015
JON A'NDY
WM MWJCMI Ave.
Palau Deet, CA WM I s
Office (760) 772-719,
Fax (760) 772-7193
Pa sw (760) 776,4338
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