0005-055 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
l`_ Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
cv w Professionals Code, and my License is in full force and effect.
OM License # Lic. Class Exp. Date
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rZ L ''� 714188 E f, E 10/31/2(
o6 Z r-_ Date
lbi_, // Signature of Contractor �'! <=f
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J U C) OWNER -BUILDER DECLARATION
W WW rl- I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) License Law for the following reason:
Z_ ( ) 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).
M () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
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0)
Q ' =. WOR KER'S•COMPENSATION DECLARATION
CL
D 2 Z I. Keret:y affirm under penalty of perjury one of the following declarations:
n ~ O () I have and will maintain a certificate of consent to self -insure for workers'
K W �: compensation, as provided for by Section 3700 of the Labor Code, for the
D J Q performance of the work for which this permit is issued.
Yl Q U ( ) I have and will maintain workers' compensation insurance, as required by
U Q Section 3700 of the Labor Code, for the performance of the work for which this
L � Z permit is issued. My workers' compensation insurance carrier & policy no. are:
co 75 Carrier gC�LDIN FACILE D13. Policy No. NWC-544068-02
(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
su fect to the workers' compensation provisions of Section 3700 of the Labor
ode, I shall forthwith comply with those provisions..
I/Date:
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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
the4bove-mentioned property for inspection purposes.
4ature (Owner/Agent) .`�/ - Date •'
BUILDING PERMIT PERMIT#
DATE ` VALUATION LOT 0005,055 TRACT
2w A t 1 9
fY.bJi yJ�T�yV � 19
JOB SITE
ADDRESS .16.15 c/mQ
/
APN
769-42
OWNER
CONTRACTOR/DESIGNER/EN (NEER
CENTURY OROWELL COMMUN'1 fis
CENTURY CROW.. COMMUJIJMWS
1535 $O, m" STREET, MRx#200
1535 SO, ID" MRWf. M #200
SAN)BERNARDINO CSL 93403
SAN BE ARDWiO CA 9UO8
(909)381.6007 C 2120
/
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USE OF PERMIT
81A7OU FaA1vMY T+ , U'r WO
SFD- LAT 30 PLAN 2C PERMIT BOSS NOT INCLUDE HLOCK WALLS OR
POOL, 75% PLAN CHECK PEP, REDUCTION FOR MULTIPLE ISSUA14CE OF
SANIE PLAN TTPF.
CUSTOM CONSTRUCTION 2,597,00 3F
PORCWPATIO 2113.00SI,
>v'l.ARAOEWARPORT (ff) 11,8 .00
i
EF"rL7NTAAD cOi'i'{ p R'ri?nsm-uC'i` on
.
2261993M
P:E RMN FEE SUllOSARY
C014STRUCTIOIIIEE 101.000.418-000 $1,049.06
PLAW CHECK: VER 141-00"39-318 $212.26
M 1
MECHANICAL PER 101-000.421.000 $91.00
1n
ZLECIIIRJCAL PEP, 101-000-420-€700 $136.50
PLUMBINOlis; 101.000419.000 $168.50
STRONCY MOTY.ON FFF, • RESID 101-000-241-0010 $31.70
ORAD NG F R 101.000.423,-000
DZrVMk1PER.IMPACT I Z $1,907.00
;
ART 1N PUBLIC: PLACES! - RESIE 701.000-255.000 $42,46
SUD-TOTAL.. CON=U `C r1ON` AND 1?i_*l CMMC
$3,60,42
IMS PRE; -PAM FPM
$17.00
TOTAY... P.VRIVLrrkMS D iTF NOW
$3s. "IQ
RECEIPT
DATE
BY," h'
C.
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
�j 1�
/
Underground Ducts
Ducts
Slab Grade
Steel
Return Air
Combustion Air
Roof Deck
,Z
�--
Exhaust Fans
O.K to Wrap
F.A.U.
Framing(/�/
Insulation
B�
_r �3 �t�
�/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
D 3_a dp
2
42-
SDrywall
_
Finale O ��
BLOCKWQ,IL1 APPROVALS
Final fj
POO S -/SPAS
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
Water Piping
2
Neater Final
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
r
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
Utility Notice (Perm)
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 CONCRETE UCT_ STEEL ASSEMBLY O
O POST TENSIONED CONCRETE O ASPHALT VTHER �e1J��N
O REINFORCED MASONRY O FIRE PROOFING
JOB LOCATION
'] q -b(7Cc't ;r4o sr LA Q,o%In, c�
REPORT SEQUENCE NO.
TYPE -� F STILUCTURE ^ /�
R 0 ./AS
�! �/
PERMIT ND.
DAY OF WEEK -
MATERIAL DESCRIPTION
f -3 b 0
ARCHITECT
INSPECTOR
a -M 0A
HRS. CHARGED
ENGINEER
ASSISTANTS I
HRS. CHARGED
INSPECTIONGENERAL Ce�TU a t>�QS CON�
DAoR C �+► fi t--,
-
StA a f W ZA-0 614 �- Com - t fie_ _
Mm o Ps TpoAza M A SQ3rti ,1 m a e , w e-z-
'�tlS
COPY SENT TO CLIENT O
CONTINUED ON NEXT PAGE D
PAGE OF
CERTIFICATION OF COMPLIANCE
I HEREBY CERTIFY THAT 1 HAVE INSPECTED TO THE BEST OF MV
KNOWLEDGE ALLOF 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.
fGNATURE OF REGISTERED INS CTOR
ATE F REPORT REGISTER NUMBER
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Certificate of Insulation
—.-- - ---- Your Horne has bow insulated wish CertainTeedfibcr jnsuletiorLpro&wM whieh are. desigoed- --
fe� tadaYs satiety standards and tomencoWs energy requirements.
lrobergtass is inorganic and therefore, permanently noetotunbustible, so it does not have to be treated
With. firetretandantehemiealsthffLVsilI-j**-lose their eramfiveness-uvea-tine:--lk-has-sot+MR-treated
with dmnicafs that can corrode wiring or metal. 1Fibe4asss will not absorb moisture nor gill it
�.------------•------------------ se4tto-avEr-tirrsu-ss-mmy►-other-iasulati�materials----- -- ---•-'---------
m
c This a15a certifies that ( rtainTbed Fiber Glass lnsulmtitet has b= pro�imnaally installed in this home
r to provide the following thetmat perFDnuamc&.
r Job Name: Men"Da Tack 28119 Flan #: 2C suss: _ 3
T - - --- -feat Nae: �O�a1�111: 7�67�fMna S4i lC�ca-
CE ---- -- — -- ---
Ceiling Areas R-38 Unfaced Batts Garage CcaWn@• — Non Acsras:
WMh L1vingAhme...:.. - .... -.& Jfag Amus
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1Bi#Qri�falls: R•13 tltrfiscedl3attserrl�u�:
-------_----- ---- ---- ----- ------------- With Erving Above -
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~ Iiteriar Walls: R-1 I Unlaced Batts lPetweQn Flour.
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Sub antrtaetor- OfIM& C&, Are.
z 42628 ATetle,'amQcala, Ca 92590
o St Pc
Tom Berm, GeAeral ltd ►er- 7'emeak Armen
a
r' R means resistance to heat flow. The higher the R- value; tho greater the insulating power.
Ask your builder for the tact sheet on R- values. Keep this certificate with your other
® valuod papers. If you ever sell this hemc. this ceatiflcnte should be passed an to the buyer.
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