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0005-051 (SFD)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 71418 Tf y,-„10l:11ixC bate �-1<>—v:� Signature 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 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 GOt bL`tS YAOLE IW91 Policy No. NIVC-3940"i 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 Code, I shall forthwith comply with those provisions. E(ate: - —L.,Applicant Warning: Failue 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, indemnity & 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 constriction, and hereby authorize representatives of this City to enter upon the 20ve-mentioned property for inspection purposes. Signature (Owner/Agent) r ��• /::-I Date />.,A / 5 516t /Olj • BUILDING PERMIT PERMIT# DATE VALUATION LOT Q1�70ft TRACT $2,0244M.10 55 28"119 JOB SITE APN ADDRESS 79--"-,S JDAYA 769470-022 OWNER CONTRACTOR/DESIGNER/ENGINEER "WAl Y CIROWFI 1 C--OWAUlt1IATf M CL'WLTRY CIZOW01, CO7M WL7XfM. 8 1535 20. ID MRWI 1', 8'12. 3#22 11.535 8©. "Do STMIT, MR, 011-00 LA14 BERN'ARDINO CA, 92408 SAN DIMN',AhT3WO CA 92108 (909)381-6007 csl f 2120 USE OF PERMIT SWCiU.I7A?t6I.I>YDVIIVNZ 1O VD -LOT 35 1 U I>1MMIT DOES NOT INCLUD9ZLOCIC 'sN'.AJAIS OR POOL CUSTOM COl'IfrMUC'TION $419,00 81? PORCHIPATIO 200.00 Sir OARAGUCA"OR'T (XF) 111368.00 US'12"TED COST 01r C67NS*1WUCr10.N' 242,46VA0 .PEIZ:fv ['I; MWI SUMMARY .. CONSTR11r,fION !F,E 16115000.418.000 $1,000.00 e. PLAN CHECK ME 101-000-4.39-318 $809.19 MECHA141C.AL VEE 101-000-421-000 $84.30 XLECTIUCAi,,FRE 101-00-420-000 PLUMBr9oFEE 101-000-419-000 916230 STRO140 MOTION FEI3 - MSIV 101-000-241-000 $70.25 t3RADINCIIME 101.000.4.23.000 $20,00 tis t.4 I)I;{TE1DPBR 11M PACT FZE $1,907.00 ° ,• ART IN PUBLIC PLACOI - RESIL 701-000-255.000 $20,00 FEE IMPO1T 101-000-439-318 4500..00 SUB -TOTAL COMMI:aCrION AND PLAN CBECK, $4,153.21 LE -33 PR -9 -PAW rNES -$500.00 1110TAL PEMM lva5 DUN INt)'1?4r ziw4al RECEIPT DATE BY � DATE � 1�D0 INSPECTOR - INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Underground Ducts Forms Footings Ducts Slab Grade 61e. o. (QL Return Air Steel Combustion Air Roof Deck Exhaust Fans O.K. to Wrap —Z F.A.U. Framing Compressor Insulation %fid Vents Fireplace P.L. Grills Fireplace T.O. Fans & Controls Party Wall Insulation Condensate Lines Party Wall Firewall 44 Exterior Lath�— Drywall - Int. Lath Final Final POOLS - SPAS BLOCKWALL APPROVALS steel Set Backs Electric Bond Footings J Main Drain Bond Beam Approval to Cover r ' Equipment Location Underground Electric Underground Plbg. Test Final I - • Gas Piping PLUMBING_ APPROVALS ' Gas rest _ Electric Final Waste Lines Heater Final Water Piping Plumbing Final Plumbing Top Out Equipment Enclosure Shower Pans O.K. for Finish Plaster Sewer Lateral / (®G Pool Cover Sewer Connection Encapsulation Gas Piping / Gas Test Appliances Final COMMENTS: Final X� Utility Notice (Gas) ELECTRICAL APPROVALS Temp. Power Pole Underground Conduit Rough Wiring Low Voltage Wiring Fixtures Main Service Sub Panels Exterior Receptacles G.F.I. Smoke Detectors Temp. Use of Power Final Utility Notice (Perm) v M, Mr M z Certificate of Insulation —_ Your l NuB has been insulated with CertatuTeed F'ihernlsss insulation oducls,�edtichace dBsigned _ for toda3is safety standards and tomormvds energy requirements. . Fibergloss is inorganic and therefore penzanantly amoombustiblo, so it dm not have to be treated --- —----------.-------uuithfere•calerdamtchemiwlslttatwilliigelyMse-lt►airaf3edi�nen�eovetrtuAerltl�asnotbeen�raeted---- N with chemicals that can corrode wiring or neral_ Fiberglass will no absorb moistures now wiB it time-as- ,� — ------ ---- may-other-ins�etan-®aterials:----------- .. Ibis also certifies that CettainTeW I$ber Glass hm1atioa has bem profisslonally iastalled-is thi Witeme to provide the following dwinal perf mmmor- `I-- J& Pbune: Mandnrina ------ Thmi: 28719 nm If: IHR > 1 z Ceiling Area: R-39 Uufaoed Batts Garage Ceiling: Alan Aeccas: aJ _..._.. .. _.._. ...._ .._- WiMIAvinBAbove-. EsAerforTDalb. R 13 Un6aacd Butts - W----=-- ------- --- ---- --- — -- Overhaaw Access Attie: `-----------------1Yitlb Living Above ----- ----- ------ w ~ Between Hoar. z Intertor Wallis: R I I Urdhced Batts 0 CE SubcoRtrador.. OOJIM dadan Cm, Inc. Teuiembil, Ca 9L590 o gkmed Tom Bery :? m M41T M R- means resistance to heat flow. The higher the R- value, the greeter the insulating power. Ask your builder for the fact sheet on R- veloes, Keep this certificate with your other o slued paper. Ifyos ever sell this lsotrso, this certificate should be passed on to tbv buyer. CD N N , W REGISTERED INSPECTOR'S WEEKLY REPORT JON TANDT 37630 Medjool Ave. Palm Desert, CA 92211 Office (760) 772-7192 Fax (760) 772-7193 Pager (760) 776-3338 TYPE OF INSPECTION PERFORMED ❑ REINFORCED CONCRETE STRUCT. STEEL ASSEMBLY ❑ POST TENSIONED CONCRETE O ASPHALT ❑ REINFORCED MASONRY ❑ FIRE PROOFING ❑ -st4o P OTHER { .' w Ct1>11'I(Y JOB LOCATION �✓ ` LAaO t O TA REPORT SEOUERM NO. � TRUCTtIR OT _a S� � _T PERMIT N0. OV _ _ 6/ o DAY OF WEEK MATERIAL DESCRIPTION _ � RCHITECT INSPECTOR 3NRS. CHARGED ENGINEER ASSIST TSMC HRS. CHARGED INSPECTM G2sr► oP- owA e S M N LTes SWGI-- t J t t 2,t tin tipfes- 8� &A 61F (4'31'S 'Shag�s t y 3 G aL s toe.s -L-ar1 FsTtA40 t Ret COPY SENT TO CLIENT O CONTINUED ON NEXT 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. 1 HAVE FOUND THIS WORK TO COMPLY WITH THE APPROVED PLANS. SPECIFICATIONS. AND APPLICABLE SECTIONS OF THE %�� A - ©� of REGISTERED , � tW- I 7,5'