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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 Lic, f s^e # Lic. Class Exp. Date
1:3
Date,. �l� Signature of Contractor /�f
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 001MEN 1 A01.' 1143, Policy No. NWC-944069-08
(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
work46rs' compensation laws of California, and agree that if I should become
sudject to the workers' compensation provisions of Section 3700 of the Labor
# Pode, I shall forthwith comply with those provisions. f
rDate:Applicant`r��
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
V
eabove-mentioned property for inspection purposes.
gnature (Owner/Agent) R LL f / Date 11 led,
V -9"J") BUILDING PERMIT PERMIT#
DATE VALUATION LOT �2 TRACT
ryry4 y �t �y}
�rfrA �e .4 28119
JOB SITE
APN
ADDRESS 79-05 BAYA
769-470-022
OWNER
CONTRACTOR/DESIGNER/EN 1NEER
C:.ti:I*Tx'iT Y CROW= CC3NDAUl3:ii lE3
M TUR.Y CRC7W1i.xL COMMUNITES
1135 so, °7.;° BI".fS'.i:*� L �'T"9 ##200
1535 301 "Do S1'REZA SM #200
SA14:13M AR1INO CA 92408
INAKBLWARD:t1+i0 CA. 92409
(905)381.6007 C1 IJJ 2120
USE OF PERMIT �
SWGLE.R-AMLY 1 .WM1,117'0•
SI}'Dy ILOT 54 P1.,AN 2AId.RRMI'1 DOES NOT iNi:i UDM, I71.,OC'X' WALTZ OR.
Mot,
r
CUSTOM CONSTRUCTION .' U07.00 OF
PORCfWA.TIO ' 212.00 SF
OAAALGEIC.ARPORT (19P) 1111458.00
XMM"Im COST CrF ICONS 11MC 0110
216,993."
PF 1 UF� S'UMVAR`Y
C. t?1J1TR.U'CT$ON F.E9 101.000.418.000 $1,0491.00
PLAN CNLt',,. K FEE, 101 -WO -439-318 $849.04
MEC' iANICAL FIM 101.000-421.000 $91,00
- -
E1yEC:TIt1C;AI. FEE 101-000-420-000 $06.90
P1d1J1Jti INO FEIr 101.1100-41940U0 $168.30
STRONO MOTION FEN a RES117 101-000-241-000 $71.70
C1I` ADINO PRE 101.000.423.000 $24,00
DEVELOPPR I1u PACT 1 'U $1,907.00
ART IN PUSIX PLACL3 - RESIL 701.000-255.000 $42.46
'nE DEPOSIT 101-000-439-318 .".00
...
SM -TOTAL CCDMMgTC 09ANtD 1PLJKN CF3fEIZ _1C
$4,285.20
LEM PRE -PAW'
4730,(1(1
TOM PERM FEES XTE NOW
��r5z��:2�►
RECEIPT
DATE
BYE
D 7 E7 INAL6D D
INSPECTOR
ro
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
E BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
Underground Ducts
Ducts
Slab Grade a 6e -A-,.—
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap _p p
F.A.U.
Framing
Compressor
Insulation ,2'
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath .�
Drywall - Int. Lath
Final
Final
C _
POOL - PAS
BLOCKW LI 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
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
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. 00-1
Smoke Detectors
Temp. Use of Power Vv
Final s --0
Utility Notice (Perm)
't r. w
Certificate of Insulation
Your Home has been insulated with CertainTeed Fiberglass Insulation products, which are designed
for today's safety standards and tomorrow's energy requirements.
Fiberglass is inorganic and therefore permanently noncombustible, so it does not have to be treated
with fire -retardant chemicals that will likely lose their effectiveness over time. It has not been treated
with chemicals that can corrode wiring or metal. Fiberglass will not absorb moisture nor will it
settle over time as may other insulation materials.
`.r This�also certifies that CertainTeed Fiber Glass Insulation has been professionally installed in this home
to provide the following thermal performance..
Job Name: Mandarina Tract: 28719 Plan #: 2AR Phase: 1
r Lot No.: 54 Job Address: 79-635 Baya Street, La Quinta, Ca
-Ceiling Area: R-38 Unfaced Batts Garage Ceiling: Non Access: _
With Living Above & Sloping Areas
,; Exterior Walls: R-13 Unfaced Batts
. . Overhangs: Access Attic: _
With Living Above
Interior Walls: R-11 Unfaced Batts Between Floor: _
Subcontractor.. OJ Insulation Co., Inc.
✓42620 Nedo, Temecula, Ca 92590
Siened I
Tom Berry, General Ma g r- Temecula Branch
R -.means resistance to heat flow. The higher the R- value, the greater the insulating power.
Ask your builder for the fact sheet on R- values. Keep this certificate with 'your other
valued papers. If you ever sell this home, this certificate should be passed on to the buyer.