0005-053 (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 Coded and my License is in full force and effect.
License # Lic. Class Exp. Date
� 714188 I3 r� �„ 1tJ131f3C
atec �_ /' 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).
( ) 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
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 GOLDEN KAOLS INS, Policy No. 14WC-54 9068-02
(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
CoiTe, I shall forthwith comply with those provisions.
PDate: crr�f r`. F- Applicant
Al
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. j�
kSignature (Owner/Agent) _ !�" �( fir• 1� } Date / / !
�l BUILDING PERMIT PERMO
"M.
,DATE VALUATION LOT TRACT
$216, WSO 3Z 29719
JOB SITE
APN
ADDRESS 19-C ("70n MV0
76949() O 12
OWNER
CONTRACTOR / DESIGNER / ENGINEER
CEI'MMY CROWI?M COMMLIN 8
Ckt, 47 URY CROW=L CO_M inINITIM
153 5;301 °D` 31..1'.Rl'?T, ZrM�. #x00
152513(), "v ulpimT. srm.. #2100
SAN WMNARDINO CA 92408
SAN BERNARDINO CA 92409
(909)381-6007 CBIX- 2120
USE OF PERMIT
0WOLE FAMFLY gJVVFYs.LWG
SFD-LOT 33 PLAN 2AR Pl£MIT DOES NOT INCLUDE, BLOCK WALLS OR
POO6 7S'Yo PLAN CHECK PER REDUCTION FOR MUT TIPLE ISSUA14CR OF
SAME PLAN TYPR
CUSTOM CONSTRUCTION 2397.00 SF
PORCH/PATIO .212.00 Sly
0A11AMUCA.TiPORT (91j 111859.90
EST:[NU1.XD COST OF CONSMU'C77ON
216,9&190
PM41T FEW 9iiA04ARY
CONSTRUCTION FEE 101.0(W-418.000 31;049.00
PLA14 C:HIECIC FEE 101-000-439-318 $212.16
MECHA141CAL FEE 191.000-421-000 $91,00
E1.E flUC:AL FEB 101 -000 -*420-000 $1; 5.50
' PLUMBING FEE 101 -WO-419-000 $163.30
.. k
STRONO MOTION FEE - R 5113 101-000-241-000 $21.170
•, .�
GRADYNOFER 101¢000.4234000 $20,00
Vow
DEVL?LOPEA IMPACT FEE $4907.00
ART al PUBLIC PLACES RESIE 701000„155.000 $41,46
� � °. •' �
31U1 j -`l -TOTAL C;O1, SMT-rCTION AND fix. A1Nt C HFZ-K
1233 PRE-PATO:F-nS
$0.00
TOTAL PEAT YM DUE NOW
:648>42
A
RECEIPT
DATE
BY' f
DATE FINALED
INSPECTOR
/ C__
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return:Air
gel?
Steel
Combustion Air '
Roof Deck ����'/,_
'
Exhaust Fans.
Zf
O.K to Wrap 0=�y�-d !�i�j
F.A.U.
Framing
Compressor
Insulation %L/7—per 6
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall -Int. Lath�z—l��y-v
Final
Final
POOLS - SPAS
BLOCKWALiL APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg:7est
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
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 --O
Utility Notice (Perm)
Certificate of insulation
— -- 3Caav�ome_has.hees3r�ulatedwith-Gerin'i'ss�F�erglaas-Ynsulation-produd�which-amd -
for today's safety stutdards and temtorm rls energy raquimtnents.
Fiberglass is inorganic ami therefore peYmanettiy noneombnstible, so it does not have to be treated
-- --- --- --- ----------------wig-fir8 ratasdantBtcemiceEsrthaetirill-lilvelyinseilt�rvcnt►"3t�esnot aeii- - --
N wtsith eherawabrat can cotrode eviring or nMal. P'bergless viii tut afssnrb moisture nor will it _.._
---- -- —sem4e overtiAro as may cstYe�dfi�riiat3�i6 s�aa et—rials. -
m
This also certifies that CertainTeW tFiber.Gloss Insulation has been professionally instetl8d in this home
to provide the fblltrtving thermal pertormanom.
r Jeb Mme: Maodurina - Track - 39719 !Pian N: 2AH Phage: 1
TXMrew. _ 9S Catrin Street: I.aQaintn. Cs — — — ---
�. Ceiling Area: R-39 Vidaced Bab Garage Ceiling: Nam Access:
3 ... .. ........._.... ---... tb Irving Above " -&-Sloping Areas
Foerior Wally: ft -13 Unfaced Batts
W —-------- - ------ ----- ------ -- With Living Above tii�een Ftoer--
zo 'imterior Walls: R-1 l Unfaoed $efts —
Q Snbconkoctor- OJ Insnk ion Co liar.
? Itio cd% TemecuhN Co 92590
o Signed
- tz
Tom Berry, General Mmqg06 Tewcule.Branch
R- means resistance to heat flow- The hfgher the R- value tho greater the insalating power.
Ark your builder for the fact sheet an R- values. Keep this certificate with your other
valued papers, Wyou ever tell this home. this certificate mould be passed en to the buyer.
- err- f
M a RM M
REGISTERED INSPECTOR'S WEEKLY REPORT
JON TANDY
37630 Medjool Ave.
Palm Desert, CA 92211
Office (760) 772-7192
Fax (760) 772-7193
Pager (760) 776-3338
TYPE OF
INSPECTION
PERFORMED
O REINFORCED CONCRETEUCT. STEEL ASSEMBLY O -' 140 IP
O POST TENSIONED CONCRETE ❑ ASPHALT pTHER o
O REINFORCED MASONRY O FIRE PROOFING W�
JOB LOCATION
REPORT SEOUENCE NO:
TYPE F STILUCTURE w
t`
LIDT
PERMIT NO.
5 ` U 7D
151
DAY OF WEEK
MATERIALE[[LED•SCRIPTION
RCHITECT
INSPECTOR
NRS. CHARGED
E-i01� Sw► ��
ENGINEER
ASSISTANTS
NRS. CHARGED
INSPECTIONGENERAL
o" CONTRACTOR ��taTU d Wn Q5 CONTRACTOR CZ j t-� k lIE-S
-TD
COPY SENT TO CLIENT 0
CONTINUED ON NEXT PAGE O
PAGE OF
CERTIFICATION OF COMPLIANCE
I HEREBY CERTIFY THAT I HAVE INSPECTED TO THE BEST OF MV
KNOWLEDGE ALL OF THE ABOVE REPORTED WORK UNLESS OTHERWISE
NOTED. I HAVE FOUND THIS WORK TO COMPLY WITH THE APPROVED
PLANS. SPECIFICATIONS. AND APPLICABLE SECTIONS OF THE
GOVERNING BUILDING LAWS.
G TURE OF REGISTERED INS CTOR
i5 0-0 `A� D `b'�-I
ATE OF REPORT REGISTER NUMBER