0005-056 (SFD)11
LICENSED CONTRACTOR DECLARATION
1 he
N Chap'.9reby affirm under penalty of perjury that I am licensed under provisions of
NPpl f er 2(pommencing with Section 7000) of Division 3 of the Business and
N W sionals Code, and my License is in full force and effect.
C)7 License # Lic. Class Exp. Date
N d / t
t— W r / "114I$t B ..� ,;1' 10131/2t
t—
r' ate �!Signature of Contractor ������% • �/�
JO OWNER -BUILDER DECLARATION
ff W W r— 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).
t•`) () I am exempt under Section , B&P.C. for this reason
L
N Date Signature of Owner
O.0)
Z WORKER'S COMPENSATION DECLARATION
CL
p 2 Z I hereby affirm under penalty of perjury one of the following declarations:
Lo � O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W �= compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
m Q C) ( ) I have and will maintain workers' compensation insurance, as required by
O U'Q Section 3700 of the Labor Code, for the performance of the work for which this
Il � Z permit is issued. My workers' compensation insurance carrier & policy no. are:
CarrierCK3LT. m4 mod. INS. Policy No. N'4Yd'C-544068-02
co 5)
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J (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 s. all not employ any person in any manner so as to become subject to the
w6rkerscompensation laws of California, and agree that if I should become
ubject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisionst ^
Date: <-,1e°• Ji,' f� 'Applicant 3 �`% •. -`.,�••l Aa.r
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
16
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
/tn,g'above-mentioned property for inspection purposes.
w�iynature (Owner/Agent) �11 ' � �" Date - >/— I
BUILDING PERMIT PERMIT#
DATE VALUATION LOT `056 TRACT
$231,3531* 29 28719
JOB SITE
ADDRESS 79-M O1✓'yi'.[.� o
APN
769490-042
OWNER
CONTRACTOR / DESIGNER / EN (NEER
CLNIMY. CROWFI.. COMUUN IE,,,I
C1"ATl` MY CROWELI C01V%4M1V.9
15.35 SO. 'D• S' T= UM #200
1535130. 'D" !'1'P_ T, r0'TF #200 '
SAN BERNARDINO CA 92,408
SA1d 13ERNAR31NO CA. 92408
(309)381.6007 CBL 2120
USE OF PERMIT
ENGLE FPJAU Y l i'W1✓J XWG
/ !
SFL7• LOT 29 PLAN 3CR PERMIT DOES NOT 1NCLUD1r BLOCK WALLS OR
POOL 71% PL" CHECK IEEE RE.DUCT1014 FOR MULTIPLE ISSUANCE OF
SAME PLAN TYV&
CUSTOM CONSTRUCTION 2,815.00 SF
PORCHAIAT10i Ir7.00 S9'
GARAQWCARPORT (SI) 9,976.40
E877 M.AM) COST Or CONSTRUCTIO.IN
231,3WAi(J
PERMIT TFER SUA04ARY
COINSTRUCTION FEE 101-000.418.000 9I1101.59
PLAN CHECK FFE 101-000-439-318 $222.47
MECHANICAL NEIL 1014000•.421-000 $93.50
ELECTRICAL WEE 101.000-420-000 $142.21
� • k
PLUMBINO FEE 101.000.419-000 $16$,$0
" 3 711
STRONG MOTION FEE - RESIN 101-000-241-•000
ORADINO F E 101.000-423.000 520,00
DEVELOPER IMPACT FEE $1,907,00
ART IN P•U131,IC PLACES • RE211-701.000455-000 Sid>3S
Y6 t?
8"I A -TOTAL COR WRITC'3TIO?d AND PLAN CFiI;'=
S3;761.110
S PRR-PAT]DI=
$0,00
TOTAL PMUT FEES DVE NOW
�;,7�1� :7t►
,RECEIPT
DATE
tBY J' •
DATE FINALED
INSPECTOR
INSPECTION RECORD
_A
OPERATION
DATE
INSPECTOR .
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Sit Backs
Underground Ducts
Forms 8 Footings
Ducts
Slab Grade
Return Air i
Steel
Combustion Air
Roof Peck _
Exhaust Fans
O.K. to Wrap �2 _
F.A.U.
Framing
Compressor
Insulation/ — $-v
Vents
Fireplace P.L.
Grills i
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath ' Z v;;
Final ' j
BLOCKWALL PPROVALS
Final
Steel
POOLS - PAS
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
Heater Final
Water Piping
Plumbing Final ;
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral / ZA _
Pool Cover
Sewer Connection -' U/
Encapsulation
Gas Piping
Gas Test 711-Z7i
Appliances
Final
Final
Utility Notice (Gas) I
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I. 100 oo,
Smoke Detectors _
Temp. Use of Power _
a
Final —b
Utility Notice (Perm)
COMMENTS:
Certificate of Insulation
Your Rome has been insulated with CerlainTmd Fiberglass Insulation praducts� vNch are designed
tb—HadWb9_9Te_Lysta_nNTsd tomorrowls mew requirements. --
Fiberglass is inorjwitc and therefore permanently aonoambustiibl% so it does aot7iavr to ha treated
_wltbso-rdardarit ghcmicals Odwill likely lose Meir Ofttiveness aver time. R has not been treated
N
with Chemicals that cad cwrodts wiring or m taL Fiberglass will not absarbrmisture nor zvgl it
Ln - over time as may other insulation materials.
(T — _-
This also ceatifies titat C,eriuinTeed.Fiber Gloss.1naulatipo bas baan.�ro�l6411 r imsta>ted in this hour
e` to provide the following thermal performance..
i-- -- Job Name-.A%MdpWit: 2W19 Plan 4t 3CK ffiiY
T
—� I�oB-Plra: 2�--�Ad�Baesse'7�&CGetirlao-Strest;)�-Quii�-GoF
----- ---
Z. ........
Cell Ing Arco: R-39 Un&cxd Bath Garage Celligg:
Wiihi.daing Above ...__
&SlopingAreaa
g
Z)
-.... - _ ... ............. __.
Faterler Walks R-13 Un sed Batts
Ov+erioo"M
_ . ........._.. ._.._. _
Aeaess Atlict
Zin
Walk: R -I t Unfaead Batts
Between Floor:
0
Q
SnbcoratrVefor.. Ojiffsaardon Cir., Ine.
L '
ytio edb, Temecula` Ca 929190
Signed
o
?'ossa Beny, General Memoir- 7'emeeaak Branch
R- means resistance to had flow. The higher the R value, the greater the insulating power.
Ask your builder For the foot sheet oa R- values. Keep this certificate with your other
valued papers. If you ever sell this lwme, this =tlficate should be passed on to the buyer.
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
PERFORMEO
OREINFORCED CONCRETE UCT. STEEL ASSEMBLY O S' t-; l7 1p
O POST TENSIONED CONCRETE O ASPHALT 76 TNER ! -'
O REINFORCED MASONRY 0 FIRE PROOFING ((
/
JOB LOCATION. LA 4 ,
REPORT Sf END
TYPE_OF ST URE
PERMIT NO
1> 1 • dopAV
OF WEEK
MATERIAL DESCRIPTION
ARCHITECT
INSPECTOR
HRS. CHARGED
P LJ
ENGINEER
ASSISTANTS
NRS. CNARGED
GENERAL SUB
DAIS OONTRwrw CeOTO W- a %%j0 -s CONTRACTOR CJ 1 le7S Sl1 — -�
iN G- 26 - e:> &.-so P
�iaA to Fsw-4A 3 1 R o2'i"t �I�1 tdeZ�
eus i u -e Tes i N 6,�- S1�.S
COPY SENT TO CLIENT O
CONTINUED ON NEXT PAGE O
PAGE OF
CERTIFICATION OF COMPLIANCE
i HEREBY CERTIFY THAT 1 HAVE INSPECTED TO THE BEST OF MJ
KNOWLEDGE ALL OF THE ABOVE REPORTED WORK UNLESS OTHERWISE
NOTED. t HAVE FOUND THIS WORK TO COMPLY WITH THE APPROVED
PLANS. SPECIFICATIONS. AND APPLICABLE SECTIONS OF THE
GOVERNING BUILDING LAWS.
eGNATURE OF REGISTERED INSWCTOR
l cd (3 o --tcj
TE dF REPORT REGISTER NUMBER