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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 Code, and my License is in full force and effect.
1. License # Lic. Class Exp. Date
714188, D y r � ], t1/.31 /2(
Date ` "tysignature 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 owne�,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 Siqnature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
() I havd 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 0OLDE.71 KAOLE INS Policy No. 14=444068-02
(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
dde, I shall forthwith comply with th.gse prov�iotds.
1 .Date e- f i.•= Applicant—
Warning:
pplicant 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 offissuance 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
t e above-mentioned property for inspection purposes. _
4 /_ffes `�1•� _C✓.
Signature (Owner/Agent) yo T/�� Date '-'
5/JtNI O BUILDING PERMIT PERMIT#
DATE VALUATION LOT
TRACT
17
28719
JOB SITE
ADDRESS 79-6-10 DA` A
APN
769-490-042
OWNER
CONTRACTOR/DESIGNER/ENGINEER
CF URx CROS COI NU W
CIEN .Y CROWXI L COMUNITYM
1535 8C, TP M URM, ITTF, #200
1515 50, V MIN, R 111nIF, #200
WIX Ia1 ]'A1'JiWO CA 92408
SAN 13MW.P.€D11 O
CA 02408
(909)381.6007
178141 2120
USE PERMITr
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Sro. LOT I7 PL 3CR PERMIT DOES NOT rMCLUDE OLOCK 'WAIA 3 OR
POOL
CUSTOM CONSTRUCTION i 3,8)5.00 SF
POR.0 HIPATIO 157.00 SI?
0AI:ACIFJCAR,PDXF (311) 9,4'76.40
X913M1A,TED COV OF C01VM UC"]f:tQ)N
CONSTRUCTION FES 101-000.418.000 $1,101.50
PLA14 CHECK FEE 101-000-4-39-318 $222.47
MECk1ANICAL FF.],, . , r 101 "000-421-000 S6$.S0
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EI.,EC`CRI.CAL FLN , 1011-004-420-000 $142.2I
PLUMI3INO FEE r 101.000-419.004 3168, 0
c
STRONG MOTION IEE - REND 101-000-241-000 $23.14
GRAD1140 FSE 101.000-423-000 $20.00
DEVELA)PEP, IMPACT FEE $1,90700
ART IN PUBLIC PLACES - RESK 701.100.255.000 �'"8i .38
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9f1.°74
1=3 ME -PAM 1WO
$0.00
110TAIL ]PIt'+`: S DUE NOW
;761,70
.RECEIPT
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DATEBfY%
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FI ALFD, D
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
. BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
oor
Roof Deck
Exhaust Fans
O.K. to Wrap _(y�
"I
F.A.U.
Framing
Compressor
Insulation
-1 " �a ���
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
/E
Final
—
Final
POOOS SPAS
BLOCKWA
A PROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
,6�
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
��L�_Gry
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
y9�
L
Final
COMMENTS:
Final)
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring 11011
Low Voltage Wiring
Fixtures
Main Service _
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) -•-
LI
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Certificate of Insulation
Your Hage has baea_9nslalcd �itiLCettasnT 1de�eutaiionp�dncts, ew#�icB�amaiesig�eci-
for today's safety standards and tmmorroWs enagy reWirements.
Pitterglass is inorganic and thcr+efore permanently nontembisstible, so it does not have to be tested
witltJ;re•r+eter,detet_clte<nieaLs-tlOat-vrr'ILIi$c3�iJase-their-e�i�s-over-tine-It-Itas nei-been-treated
C . with chemicals that can corrode wiring or metal. Piberghm will not ebsoib mafsure nor will it
—�11e-over-timo�'array-atlx� insWatiau-t�teria�:-------' --- --- -
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...
This also cWffiles that tkrhdnTeed Fiber -Glass Insulation has been pro&ssioially installed in thio home
W provide the follmviug thermal pe fomaaee..
N Job Name: liyendse Us Tract: 2W19 Iia 0: 3CR Phalle: -- 1
T ------
-Lut-N�I7.11►11vdd�: '79=b70�taya gtaeet; >%a �itdo;, £h— -- ------------------
Ceifing Areae R-38 Ur<feood Botts Garage CeMhW: Nos Aoaeas:
With lUviog AbAaw & Sloping Areas
CRk1 iUr Walls: A-13 U]nfaoed Batts --.-OverhKow. Access AM=
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With 13ving Above
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Rghveen
Interior Watts: R- I I Unfaced Batts �0�'
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SffbCV1 ►a &r. CDJIMUhNUN Cos, AOM
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Nede, Temeeub, Ca 92M
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Tom Benny, General
BAwwh
R- means resistance to heat tlaw.L4&r-rWgher the I; value, the gteatea the insulating power.
Ask yaw builder for the fact sheet on R- values. Keep this eediiirsita with your other
valued papers. If you ever sell this home, this certificate 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
PERFORMED
O REINFORCED CONCRETE STRUCT. STEEL ASSEMBLY. O SHO P
O POST TENSIONED CQNCRETE t0'ASPHALT OTHER t .) d .�
O REINFORCED MASONRY O FIRE PROOFING W Ln11•I &
JOB LOCATION n -' 6? 0 5F, A -S'C- LAQo l O TA
REPORT Si; 1"; NO.
QE�UCTI}R OT 1 7
PERMIT Na
OvAb �
DAY OF WEEK
IAL
MATERDESCMP�TMN n 3 ( A _��
•-
ARCHITECT
INS ly
NRS. CHARGED
C,h4,.
ENGINEER
ASSISTANTS
HRS. CHARGED
INSPECTION
"TEooNTRIYCTOR uTR
SUB
om e_S CONTIVZTO l N CM5 S�Z_
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'�S• ta.X Gals
�e tk F.S't. 40 t IRe"ZZ
Baa P-0
COPY SENT TO CLIENT O
CONTINUED 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 NAVE FOUND THIS WORK TO COMPLY WITH THE APPROVED
PLANS. SPECIFICATIONS, AND APPLICABLE SECTIONS OF THE
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�� TU�RE�OF REGISTERED.- c CTOR )-q ��