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LICENSED CONTRACTOR DECLARATION
I N-reby affirm under penalty of perjury that I am licensed under provisions of
Chaff ter 9 (commencing with Section 7000) of Division 3 of the Business and
Profes sionals Code, and my License is in full force and effect.
Licen:'�e # Lic. Class Exp. Date
7/14.1 S/8 B 10/31121
f� ,
ate `/ ��/* Signature of Contractor/22
OWNER -BUILDER DECLARATION
1 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 iSignature 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:
Carver GOL,DID1 ]?A.014; YNS, Policy No. NtfiiG ; �Ipbit-0Y
(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
work rs' 'compensation laws of California, and agree that if I should become
suPrEect to the workers' compensation provisions of Section 3700 of the Labor
,Q -ode, I shall forthwith comply with;those provisions.
/Date: `5 Q �Applicant-
1
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the bo
ve-mentioned property for inspection purposes. _
Si?ature (Owner/Agent)/4'q'y/'t `" Date
9?tr BUILDING PERMIT PERMIT#
DATE VALUATION LOT 0005••(A4 TRACT
3'2.31,353.00 31 28718
JOB SITE
ADDRESSia A�1N0
APN
769-4442
OWNER
CONTRACTOR/DESIGNER/ENGINEER
LUTMY CROWELL CObdMTJ lITM
CMNrMY CROV&L,L C0NQAVNI7=
1533 30. 'D" 12TIMM, 41200
1535.30. "De SOT= , fM 4200
SAN BF"ARDIiv" O C.A. 92408
SAN PFS NARDINC CA 92408
(908)381.6007 CBLO 21 ZO
USE OF PERMIT
SiNGIZ FAMILY DWMLxZ%J'ti
S70 -LOT 31 PLAN RAR PPRMYC DOES NOT INCLUDE BLOCK WA LS OR
POOL ?$% PLAN CHWK FEF REDUCTION FOR MULTIPLE ISSUANCE. OF
SAME PLAN TYPE
CUSTOM C011f TR.UCTION 2815,00 3F
PORCH/PATIO 157.00 SF
CARAOM,A•RPORT (SF) 9.9W.40
i
ESTMAIWD CVYr OF C0A.S7RUCnO11
23113X400
P Li 'Ci' FEE 9UMMARY
COAIS7'Rt1GTlON Fir 101.000x418-000 51,101.50
2 f
PLAN'CP><ECK FFA?, 101-000-439.318 $222,47
c =
M.7WHAkNICAL 1E8 101-000-121.000 $98.50
ELECTRICAL PY2 101.000-420-000 $142.21
PL,Ui4 BI' 4 AEE 101.000.419.000 116& 50
3_
STRONQ MOTION ISE • RESID 101-000-241-000 $23.14
�� ; •. 3 ; {
QR.ADINO FU 101-000423-000 $20.00
„,, j, r 4 ti,,.•
DEIEL.OPER. IMPACT Fi;L $1,90'.00
ART IN PUBLIC PL,ACM - RES11701.000.255-000 37 .3$
�•
8`tiB-TOTAL. COM:tRUCTION AND PLAN (MIECK
$3,761.70
LESS PRE. -PAID F`I=
;$0,00
TOTAL PMU DLTE NOW
X3,7[1.74
RECEIPT
DATE
Y /
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
f
OPERATION
DATE
'
BUILDING
APPROVALS
_ale
Set Backs
Underground Ducts
Forms & Footings
Ducts
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
f, p,
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O. K. to Wrap
F.A.U.
Framing
_
Compressor
Insulation
— 12-0
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation "l
Condensate Lines
Party Wall Firewall
Exterior Lath
B�
Drywall - Int. Lath
_oma
Final
Final
POOL S - /so AS
BLOCKWA
L APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
s p8
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)
ELECTRIC
L APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
100 01
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
r')
1-40
0
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Certificate of Insulation
Your Home has been insulated with CertatnTeedBbergtass_insLlation-producor"ich-are-designed —
` for today's safety stondards and tomorrows energy requirements.
Fiberglass is i=gsnic and there6are permaneatiy mmicontbustible, so it does not have to be treated
u�rith�e�eat_ehergi�latfiat-will-likely-fie-their-e�aativeness-over-time: Ii-hes-not-�rtreated--- ----- -------- —
CO
--- -- - -- - -- --- with chemicals abut can corrode wiring or metal- Fiberglass will! not absorb moisture nor will it
LO
-. ----- seftle over 4in�c�as may other insulatiaa matedafs.—
m ,
This also eertifes that CertainTeed-Fiber-Glass insulation- has been professionally insteRed in ibis horns
" to provide the follrnving thermal perfortnance..
�D -- Joh Name: Mandarina Taact:: 28719 Pian El: 3AN )Pitsea: _ 1
r
Ceiling Arco: R-38 Uniaoed Batts CVWQg4V CeUag: rquaAceew.
-... With Living Uwe ......... .. .. _......... � �iag Areas.. _ .... ..... - . _ .... .
g>i ate�or Wags: R 13 >EJnfaoed Batts
Access AM ----- - ------ --- --- -
w - — - -- With Llving Above
W
~ Between! Main.
z Infmior WoUs: R-1 I Unfiwed Batts
0
Cr Subcv &dw*w . OJ InsulgWon Co., INC.
Z _ 4zsx� ea.� Temeeata � szs�o
Signed.0
Ton Bette, Gewral Ao� Temeculet Brash
m
R- means resistance to heat flow. The higher the it- value,, the greater the insulating power.
Ask your builder for the goat sheet on R- values. Keep ibis certificate with your other
valued papers. Ifyou ever sell this home, this certificate should be -passed on to the buyer.
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'SPECIAL INSPECTION SERVICEI
REGISTERED INSPECTOR'S WEEKLY REPORT
JON TANDY
37630 Medjool Ave.
Palm Desert,CA 92211
.ej
Office (760) 772-7192
Fax (760) 772-7193
Pager (760) 776-3338
TYPE OF
INSPECTION
PERFORMED
O REINFORCED CONCRETE CT. STEEL ASSEMBLY O S 14 a go
O POST TENSIONED CONCRETE O ASPNALT L�QTHER
O REINFORCED MASONRY O FIRE PROOFING f1 We_4 `)
JOB LOCATION Cj_ j Q
REPORT SEQUENCE NOAr.
T� F ST�CTURE D� (>14AS 6- M
PERMIT NO.
pATE ;Gl 0�
DAY OF WEEK
MATERIAL DESCRIPTION
R A a
ARCHITECT
EC
INSPECTOR
11� 041-
NRS. CHARGED
E`7O 0 3 -SYK A
-`7003
LCALo
ENGINEER
ASSISTANTS
NRS, CHARGED
T O T�1 Ce�TU a tr�eSMMACTORCcs k -S !S'j-,
0,I--sc. (^-Te�s P
(3 5 'M
,94aW 61.1 6ew'-p 6e-pt �
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.�'vAN �s7e� �IgI��� d�!►��i«�e.Z
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COPY SENT TO CLIENT D
CONTINUED ON NEXT PAGED
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.
o
IG , TURE OF REGISTERED INS CTOR
ft xs.
TE6A6F REPORT REGISTER NUMBER