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LICENSED CONTRACTOR DECLARATION
Thereby 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
"a 1777.0 C29 0111.11/2(
Date Signature of Contractor ✓ f ��
OWNER -BUILDER DECLARATION i
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&RC. 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.
() Hl.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 Policy No.
3'YATE F 32�t'ly� 16471734
(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
Code, I shall forthwith comply with those provisions.
Date: Applicant— .t^"
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
Yl
of the Labor Code, interest and attorney's fees. 41
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. 1a
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, inclemnify g
& 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.
Signature (Owner/Agent) Date
�;:
BUILDING PERMIT PERMIT#
DATE VALUATION LOT (iIfDJ. TRACT
L G r2l&w 26 2P,19
JOB SV E
APN
ADDRESS
i -'x.15 CMIND
..
OWNER
CONTRACTOR/DESIGNER/EN (NEER
C= C7:RY CROWELL COivtMLi27` Ir's
.Yj', itz FTWOR ;tA.d CklRY
13335, SO. 'Do VMIMT, q,,rF— 02,00
'113-990 DAYBEIRRYLANE,
SAM CAA. 92408
1AQVU4TA CA 122-13
Q60)772-3036 CRT.;dl 5713
USE OF PERMIT
2f3 LF. YN 0ARDEN W.AU.. (POOL XQUr.F`MYNT ff NC € S1JRtr,) Oto .Y.A•S
PEIR APPR .3VERT) MAWS
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.7.D.c��J r .S�M.Cif.Pv SUMMARY
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WfISTRUCTICY." FEE 101 _X30-141 8_000 $15,00
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> LTE?,-:d'CT Ai:. C 03,4011Mt"' ON .AND PLAN' L'E#ECK
$15,00
SAX KA14 PE1WXX' a d.F8 d.AUE NOJ 87
RECEIPT
DTE /
BY ,% OK /
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
'MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor I
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - int. Lath
Final
Final
BLOCKWALL APPROVALS
Set Backs _ _
Footings
steel
Electric Bond
Main Drain
POOLS - SPAS
— — — -
_
,
Bond Beam—/—O /
Approval to Cover
Equipment Location
Underground Electric
_ _
Final ` Z�_6t/
PLUMBING A5�PROVALS
Underground Plbg. Test
Gas Piping
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
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)
COMMENTS:
A RE -INSPECTION FEE OF $30.
WILL BE CHARGED IF THE APPROVED
PLANS AND 10B CARD ARE NOT ON
THE SITE FOR A SCHEDULED
INSPECTION.
NO EXCEPTIONSI
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BUILDING & SAFETY DEPT.
APPROVED
FOR ON TRUCTION
DATE
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Ceiliag Area: R-38 Unhmd Batts Gump Celliag: Non Aeeem
Vi+ith Uving Above & sloping Areas
Bateriw Vi+dW R-13 UnfaeedBatts _A cesAttie_r_--
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lnbedor Wags: R -i 1 Uafaced Batts Betweeen) loor:
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Signed
Torr Be»y, Geneva! Manager- TM42 Brnneh
R- means resistance to heat flow. The higher the R- vai►q the greater the insvWmg power.
Ask your builder for the fact sheet on R- vakm& Keep this oertifi ale wM your other
vatsod ptepw Tfyou ever W1Misbum% thy certificate should be passed to to the buyer-
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----------.. Your Homo has been insulated-vyMLCzlsit►TaodFibergbmIns olattoaproducl%-"Ich_sre.designed ---
for todays satiety standaub lead totnorrrnv's energy regairetaent&
F iborglass is inorganic and thcreore penuantatly noncombustible, ser it chess nut have to be treated
----- ---.---wiW�.retardant�ineis.tlartvv7L6tely-lose-their-effso+�tima: It-i3�as-itot-boco-t�ad--------------- - ----
with dwnic ah that ane eorro& wiring or mewl. Fiberglass Will not absorb moisture nor Witt it
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This also certifies; chat CevtairiTeed Fiber GlaS bmteBon has beea professionally mmiled in this }vane
to provide the fdlowiag thcraml perfanwo -
--,fob Plante: Niaadnim 'lb wh 28719 Fbntfc 3B -Plisse: I — — -
`--- --)ruCNa: ---�- aaU Ai! -dreg : 7�„7t5CelrL`o3lreet;Ze-Q�nta, Ca --------------
Ceiliag Area: R-38 Unhmd Batts Gump Celliag: Non Aeeem
Vi+ith Uving Above & sloping Areas
Bateriw Vi+dW R-13 UnfaeedBatts _A cesAttie_r_--
With L t ft Above
lnbedor Wags: R -i 1 Uafaced Batts Betweeen) loor:
SubcOM&O Yor. _ OJ Insn";Ou Co., Iw.
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Signed
Torr Be»y, Geneva! Manager- TM42 Brnneh
R- means resistance to heat flow. The higher the R- vai►q the greater the insvWmg power.
Ask your builder for the fact sheet on R- vakm& Keep this oertifi ale wM your other
vatsod ptepw Tfyou ever W1Misbum% thy certificate should be passed to to the buyer-
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,SPECIAL INSPECTION SERVICEJ
REGISTERED INSPECTOR'S WEEKLY REPORT
-ANDY
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 S t40 1p
O POST TENSIONED CONCRETE O ASPHALT INNER o
0 REINFORCED MASONRY O FIRE PROOFING W�� 3j
JOB LOCATION LA ku w -
S t
REPORT SEQUENCE No.�a
` S7FU D6- *L A& QNAs E T
PERMIT NQ
T ' �
DAY OF WEEK
MATERIAL DESCRIPTION-3
`�ARCHITECT
INSPECTOR
NRS. CHARGED
_`7O18 li 0
E-`7018
ENGINEER
ASSISTANTS
HRS CHARGEO
-
EIr"°N CONTRACTOR C
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COPY SENT TO CLIENT O
CONTINUEO ON NEXT PAGE O
PAGE OF
CERTIFICATION OF COMPLIANCE
'HEREBY CERTIFY THAT 1 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 TUR
E OF REGISTERED If4swcToR.
0 ro a
DAT F REPORT REGISTER NUMBER