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CIS 5
0
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.
License # Lic. Class Exp. Date
7141$$/, 13 �5 �,✓ 10131/20
Date Signature of Contractor _
If
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 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 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.
( ) 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 OOLDEN VA01A INS'.• Policy No. A WC-S440t35.02
(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
sybject to the workers' compensation provisions of Section 3700 of the Labor
ode, I shall forthwith comply with those provisions. /
Date: r—i", Applicant—
,
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penaltiespild 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.
c?nstruction, and hereby authorize representatives_ of this City to enter upon
te above-mentioned property for inspection purposes.
ignature (Owner/Agent)r��� � A, � A/: -/tea Date 2
j f r BUILDING PERMIT PERMIT#
DATE VALUATION LOT 000S'1%9 TRACT
'"2Cf14S8.2f1 16 28719
JOB SITE
APN
ADDRESS 79-660 X)AYA
769-490-0421
OWNER
CONTRACTOR/DESIGNER/ENGINEER
ChNI TURP CROW LL CONDIviCWIT'a',
(71liXM Y CROW CON04'0191:11ES
1535130. w7° WlF'S .'T1X 4206
1535 so. "A" nfsn7, X1.7.0,2.00
SM BRU, ARi71NO CA 92408
SAN B;NMMAP LIDTO CA.. MOB
(909)381.6007 C'M11 2120
USE OF PERMIT 1
SPD. LOT IS PL 1A PERMIT D09S NOT INCL.UIX BLOCK WALLS OR
P006 75% PLAN CHEM;: F1:1, REDUCTION FOR A+Si. LTIPbE. IMIANCE OF
$AME PLA14 TYPE.
CUSTOM CONSTRUCTION 7,419.00 SF
PORCHIPATIO 200.00 Sr
OA'�ACI17lCAitAG1RT (SIS ]1,31;3.04 .
M;t11/1A'M C`:OSS' 01T CONSKRUC.i IM
202.46V.10
;PERMU M, 5'TTMM RY
i .I w.1
CONSTRUCTION FEE 101.000.418.000 g1po.00
PLAN CHECK [EE 101-000-439-318
MECHANICAL FEE 101-000-4e21-000 $84.50
£ f4
F-LEC.TRJCALFEE 101-000-420-000 $129.77
Z�
PLUMBrNG FEi? 101.000-41.9000 $162,50
STRONG MOTION ISE - RESID 101-000-Ul -000
GRADING I<`YE 101-000-423.000 $70.00
DEVELOPER IMP.AL:T.10L]N
AFT IN PUBLIC PLACES - RES[[ 701 A0004255.000 $20.00
�t3B-TOi`AL CCii3'u�.t't" lM0siAJ>') EYLAN CkI-Mi
V3,546.32
_ LEW M1&PAID Rix, �
$0.00
Wt MI2TO..�.rf7 EX -6 IT iYO!N
RECEIPT
DATE
BY��
DA E N ),ED./
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
06
Ducts
Slab Grade
--0-0
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
�2(P_� _
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lathy
--moo
Drywall - Int. Lath
Final
Final
POOL - PAS
BLOCKWALL 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
—ca
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
Appfiances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAV A PROVALS
Temp. Power Pole
-
Underground Conduit
Rough Wiring
Law Voltage Wiring
Fbctures
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
g Certificate of Insulation
-..--Yimr-l3amahas-beeminsubded-with`CertainTMAF>'6e�glam hmiation prodactp.yAich aredesigned
far today's safety staadards attd tamorraWs energy► ra¢rireruettts.
Fiberglass is inorganic and therefore poreattentiy noncombustible, ser it does not have to be keeled
--- -- - ----- -- ----with-iFrew+atardHat-che�niesbitletwig-4kciy-loea�ih��e�eWiv®nnessover_tdme.�.has�t_b�teasted
cv with dMm kala that can corrode wiring or mew. F1b"gk= "I not absorb moisture rear wilt it
_ —
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.-+ _ - -- -----—Settic'oYBC-tlllte-8S-iO3ty-alEtar-lrl9UlatiOR-Alaier19t9r— ------
M
r. . . • . •- . . This also certifies -that CertainTMA Fiber Glass Inulation-has bcOb pevfiassienally iustaffed in this home
pm
m to pide the following theesul performmme .
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I` Jab Name: fl auftrinn Track M719 MUNI 3A
Pirie: 1
T
_ I1Tii: - Tb--�i�A�d 79= WB'aya Sbrcet.-IA IQuhagua %,a
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-
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w Ceiling Am: R-38 Unfaced Batts liarsge Ceiliry _
Nm Ateess:
R►ith LivingAdsve . _ .. _.............
.dk Siopig Acnes
0 Exterior WaM: W13 Untirccd Batts
—.---_--- - Ov+esbseeg
g Certificate of Insulation
-..--Yimr-l3amahas-beeminsubded-with`CertainTMAF>'6e�glam hmiation prodactp.yAich aredesigned
far today's safety staadards attd tamorraWs energy► ra¢rireruettts.
Fiberglass is inorganic and therefore poreattentiy noncombustible, ser it does not have to be keeled
--- -- - ----- -- ----with-iFrew+atardHat-che�niesbitletwig-4kciy-loea�ih��e�eWiv®nnessover_tdme.�.has�t_b�teasted
cv with dMm kala that can corrode wiring or mew. F1b"gk= "I not absorb moisture rear wilt it
_ —
4D
.-+ _ - -- -----—Settic'oYBC-tlllte-8S-iO3ty-alEtar-lrl9UlatiOR-Alaier19t9r— ------
M
r. . . • . •- . . This also certifies -that CertainTMA Fiber Glass Inulation-has bcOb pevfiassienally iustaffed in this home
pm
m to pide the following theesul performmme .
---
ko -
I` Jab Name: fl auftrinn Track M719 MUNI 3A
Pirie: 1
T
_ I1Tii: - Tb--�i�A�d 79= WB'aya Sbrcet.-IA IQuhagua %,a
U
z
w Ceiling Am: R-38 Unfaced Batts liarsge Ceiliry _
Nm Ateess:
R►ith LivingAdsve . _ .. _.............
.dk Siopig Acnes
0 Exterior WaM: W13 Untirccd Batts
—.---_--- - Ov+esbseeg
Access Atkic:
-- -------- — -... — -- - - With 1i.ivaeg Abam ---
W --
-- - --
w
f -
z Interior tAfalts: R ns 11 Unfaced Be
Between 1?to: --
0
Q Subcawtractor.. GJ Amola on CBI., Int~
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4, Z�.Re'o Ne4%macula, Ca 9259U
o Signed V
Tam Berms, GMeeal ]�ge emecm% Bmuch
R enters resistance to heat flow. 4 a higher tles R value, the greater the insulating power.
Ask your buihler for the fact sheet on Ra values. Keep this certificate with your other
valued papem lfyau ever sell thishame, this ocrtificale should be passed on is the buyer.
lD �
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 POST TENSIONED CONCRETE O ASPHALT
O REINFORCED MASONRY O FIRE PROOFING
OS O r
(OTHER { �
( W
JOB LOCATION LOCATION 79/p o VS
(7C
'"C� ` F1 A MCIl L V i O A
vAL
REPORT SEQUENCE NO.
UCTl�E �
� r
N(Vc
PERMIT
TE
DAY OF WEEK
MATERIAL DESCRIPTION A� A
`Kl_
ARCHITECT
�OA
NRS. CHARGED
t CIF#,.
ENGINEER
ASSISTANTS
NRS. CHARGED
DAN.�CitON
aM Top
OYA e_CONTRACTOR M tT65 Ste_
�b
0J9 Se`sUgt� Lam?e Lln, its
5&0We-ao:N Gait
COPY SENT TO CLIENT O
CONTINUED ON NEM PAGE O
PAGE OF
CERTIFICATION OF COMPLIANCE
1 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
rGN TURE
V o OF REGISTERED...A..��, CT����