0011-261 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter g (commencing with Section 7000) of Division 3 of the Business and
i�Profe Dnals Code, and my License is in full force and effect.
Licens # Lic. Class Exp. Date
`i 1/41$ 1i y i 1%►dry1,`Z
ate- 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:
( ) 1, 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.Q. for this reason-
Date
easonDate 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
Sec on 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.
0OLDEN ZA01:9IMS. NWC44408-02
(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
subj ct to the workers' compensation provisions of Section 3700 of the Labor
Canfle, I shall forthwith comply with those provisions:
ate: %:.J,�. > Applicant
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 personrat r
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 employeesµ
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
co struction, and hereby authorize representatives of this City to enter upon
th above-mentioned property for inspection purposes. '
��ff �
VSignature (Owner/Agent) '� - ' � Z 4", Datef
BUILDING PERMIT PERMITN
DATE %h, VALUATION LOT0�I•61 TRACT
�
J/fr r.4 2X19
JOB SITE
ADDRESS •79-4WO 33AY A
APN
•
OWNER
CONTRACTOR/DESIGNER / ENGINEER
:Kwmy, MJmL w vr6bO
CL•a4rIlYAY CR,0TYJUdy pVn111
1 X35 so, aDs syrr, r, via #290
1:535 00, "7 =KFI '; =4 #200
SAN BF.RbIARDIX0 CA 9240'a
���
,S A3J BTMMAT�l'.11,1•TO ; r• /Lf�9'2R' 09
5.6007 �' Wt, 2120
USE OF PERMIT
R,OT 14, PLAN AJ; 5111) �e ZaFRMIT DORS NOT INC1.401! Bt.'CK WALL%
POOL, OR DRIVEWAY APPROACH. 111." C34940K FES? PXDUC.ZD 75`,, FOR
MUTAIPIX,1'S i004VE OF is ML? PLAN 7`1CP&
CUSTOM CONSTRIK'1 014 ;L,197.00 SP
PORC"81PATIO 213.00 By
CIARAA4sE9wrora (sn;+ 11.$140
.t@QS.2,L%18'tdT.M+I C`IIAY,f 6 %, F CadN.6J4.Khh8.1G,-MO
- - 216,50W3
FERMMrye SuMbLIM i
CONSTRUC-TION .7Z 101►000-419 R3 -(*0 $1,04.9100
3?LA34 C1'iEVK FEC 1014100-439-318 $212.26
M1WHANICTAL PEE 101.000`421.000 591.0.
SR.IrCTRICAJ, RZE 10.1440.420-000 $144.00
PLq.Ttv3Rl1NG F99 .101-000-419-000 00-X319.000 $143.58
STRONG Y"A.C3Ji'ION FEE.' d R 10 1, O i -N104A $ -000
ORADIRO ti' E 101.000 -be -000-4A -ON $20.08. .
i3ZV11i OPER.) IMPACT "X $1,907.fig
ART tH PUBLIC PIALA. - PLE.9.11r 701-000.255.00.0 X42,46
'.. S1.T-lC}°1`4~112.1C'1?eA111?1r�1�A��g1�y'��TF9`.q'tys,
$3,�i�5{,�5y.��,��y
�y
110 Z'.nb�:r".G`d�i.,1� 1 ' 7
$0, 00
DEC 12 2000 OTAL 14.MMIDIT-i- NOW
DATE
B
6
DAT F ALE7RECEIPT
3
INSPECTOROr
0
INSPECTION RECORD
..
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
k BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
j'(�— (�
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
6�yzm
Exhaust Fans
O.K. to Wrap
_
_
F.A.U.
Framing
Compressor
Insulation
_ ���� �j
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
6
Drywall - Int. Lath
Final
�l
Final
_'3/a �—
77
POOt.S -SPAS
BLOCKWALL
APPROVALS
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
�ZB-6a
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
COMMENTS:
Final
0-r
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbitures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
_
v'
Temp. Use of Power
Final
Utility Notice (Perm)
05/24/01 THU 13:21 FAI 760 7727183 JON TANDY
REGImmm INSPECTOR'S NImI.Y REPORT
Z 013
JON �Y e
37630 aea1001:
Palm, Desert, CAM-1-1
Office (760) T72-7192
Fax (760) 772-7193
P"W (760) i76-3338
TYPE OF
INSPECTION
PlRFORMED
0 RONFORM CONCRETEBTRUCT: MELASSEM%'f
O POST TENSIONED CONCRETE O ABPNALT
0 REINPORC90 MASONRY O NRI PIIOOPINO
O St{c
�OTMER'- I
w PAZ- )%
ID. LOGTKf11r7 +d $ A A S*r-
LA a0 i 0TA
age" su1,mme.
OMSe'
_
sM4
ar Of VJUK .
WATERM GFSCIBFDWY R 3 G At -Wow,
!
NRS. CAARGED
s ICK kL,-) •
Hft c+l►IwED
CON>� 01 H
a..o
co" SENT TO "I"T 0
COMTMI tl OY Ww Fif 0
ME OF
CERTIFICATION OF COMPLIANCE
I MEREBY 0:1110tt THAT I NAVE INSPECTtb TO THE BEST Of Mil
KNUMEDGE ALL OFTHE AWK WORM VIIORX UNLESS OTHEYWISE
NOTED. I HAVE FOUND THIS WORK TO CWPLT VM THE APPRDIIED
PLANS•rSPECIFICATIOW AND APPLICABLE CWTIONS OF THE
�mKrw war n1Y/i • 11yR -
l G �yi MAI.—
DF 1 U V RIGISTEM rapier"
scscabW-17,50
r / 7 - (�j
7,50
ti lli VA%v". Fp NI smRFR
I IPA M09911..,,.__ _ ....r..._ ... __
(N
W
0
Certi*ficate of Insulation
--
-- -- Vour�lomahas-bean-in�ulatad-withGe�4�rT�d-FibergJa�-InsulatEonpmdrr6ich�re-de��ted-- - - — - .
for today's satiny standards and tomorr+ Ws energy requEmon rts.
Fibergaass is itosganic artd dieretbre permanently a mambustib* so it docs not hwe to be treated
----—
with chemicals that can corrode wiring or metal. Mcrglass will not abmb moisture nor wilt it _ -- -
..- ------
settle aver-titrfe�i��bt�>trsulatwa tna�et, ia7s-------- ---
®
This alts certifies that Cett dfiTeed Fiber Ori ss laauliitioa h�a beex profmioaaliy irtsta ' is this home
ui
to provide the following ihomal p61orumce,.
r,
(n
Job Pisan Mat<dsNarl Trete 028719 Phut q: 28 Phase; 2
- - a: 14 Job Addren: 79-649 Maya Shoat
Ceding Ann: R-38 Btowa hnuladan Garage Ceiling: 1Wa Aceem
With Living Above d< Slopleg Areaq
D -
Lrattlor Walla: R 13 MA ced Batts
- - --- - ------------- - -- - - - --- - - -
LU --- --
w
- -
With Living Above --
r -
o
Interior Wath: R-11 Unikeed Balls Between Fluor:
Q
SUbCVntrQCter.. OJ IDDM air CO., Ing
U)
?
Nedoy Temeea , Ca 9990
o
to
Signed
Tom terry, General ger- Temecula Branch
N
m
Q�
R- means resis ancc to beat now. ?'Ire higher the R -value, .the greater the iEoulating power.
Ask your builder for the fact sheet on R- values. Kecp this certificate with your other
valved papers. [fyou ever sell this home, this certifnata stsould be passed on to the buyer.
m
N
R
N
0