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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.
License # Lic. Class Exp. Date
4
ate /71�t1RAM.
£s Es . �� .3 10/31'2(
.�//> �M . 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 Policy No.
GOLDEN EA019 RM. Ni4�G-StR06B-03
(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
Cade, I shall forthwith comply with those provisions.
•Date:�`r� a' Applicant `- .,'Y') / ✓�./ �'
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
Z_ property
Jfor
jinspection purposes_
Signature (Owner/Agent)�� / /� . • ! 1� yF' �1 a Date •.� y
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PERMIT PERMIT #
��^^►► � . ,�BU""ILDING
DAT r� w) -p f v,PLUATION LOT �D��.'-.�% TRACT
216,98, 26
JOB SITE
APN
ADDRESS ,79•-6"
490-042
.769-490-042
OWNER
CONTRACTOR/DESIGNER/ENGINEER
G1rN f11>7ir '17OUv .L OO �ChtON�iTr
C:N"ET.XTcY CRO'W'E.i..-CO1M.UNff
1535 SO. flDQ UTRI .'T, mak, #200
1535 00.'0° ffREW, MU x#200
SAN 1;:1"ARIDWO OA 92408
SAN B1� 4ARD1N'Oi CA 92408
(3 09)381 oC1}p') 0BLO 2120
USE OF PERMIT
M1GLX.%8.1Wi,;;' Ii ,1.LNC3
1.04` 12, PLAN 2C; .',TD • PERMIT VOF5 NO't' WCt.,UVZ SLOCK WAT LS,
POOL,, OR D'R,iVEWA.YAPPilOC-11, PLAN CHECK FLT ltF()UCF_D?3%1f0R
MUI,T1PLT ISSUANCE OF SAMZ PI -04 TYPE.
CUSTOM CONSTRUCTION 71,397.00 OF
POR.CNIPATIO 212.00 SP
oAkiA0FJCA.RP0i .T (SF) 11,85A.00
FOLWATED COW OF 00N,';rYUCn0.N
PKT ZWI T ii'lt , 6 b U AAV
CONOTRUC:TION FEE 1011.000.418.000 $1,049,00
PLAN f;.l{LCK FEE 101.0001 4139-318 $212.26
1AEC1'ANICA0 PGE 101-000-421-000 $91.00
ELLC P Itf iw,�i f, > 1$Iw 101-000-420-000 $144,010
P dUMOTHOFm 101.000.419.000 $1410,30
STRONG MOTION ME -,REBID )01.000-241-0010 $21.10
GkikIDING FK& 101 -0001 -423 -GW $20.(101
]DEVELOPER IMPACT PEE $1,907.00
,A W -C TO PUBLIC PLACES . RESIE 701--000-25.5-000 ••000-x55-000 54146
S'UA TOTAL ('0kTMDG`Ti0X AND PLAN C1111M,
$3,655.91
DEC 12 2000 TO L:��:: Mn�CMES DTT N��
a*'IT`y Ul— LkQuivAl
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RECEIPT
DATEBYE
DAT I ALED
INSPECTOR
INSPECTION RECORD .
' OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
- BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs „ B
Underground Ducts
Forms &Footings 450.1
Ducts
Stab Grade
Return Air
Steel
Combustion Air
Roof Deck
O.K. to Wrap
Exhaust Fans
F.A.U.
Framing g �
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls i
f
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior -Lath �
Drywall -Int. Lath
Final
BLOCKWALL APPROVALS
Final
POOLS -SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric •
Underground Plbg. Test
i
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
Exterior Receptacles
G.F.I.
Sewer Connection —(.ff
Encapsulation
Gas Piping
Utility Notice (Penn)
Gas Test
Appliances
Final
COMMENTS:
I
Final
CC//
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Nottage Wiring
FuQures
Main Serv
ice
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Penn)
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Certificate of Insulation -_
—YmxHome:h s. b ant insulated with Cetta+aTeed Fie ass Insulation Products, whkh are designed
for todWs safety standards and tomowoul's energy seguiremeats.
Fiberglass is inorpnic and therefore permanently noncombutible, so it does not have to be treated
--- --- - --... ------------- ----- -- ---,evil►-Piro retaretaatehenlathat wlil_iiisely losr<thelsliectives ower time. �t not been treated --- ---
wbb cbe3 dc& that can ¢orotic wire atototal Fberglass will not absorb moisture nor will it
� ---------------------...-------=-------se111e-ovmr.time.as.may�olher•_ulautetiQn.materl�---------. —=--------.------------.
m
N Tkis atso certifies Ihat CertsinTead Atber Glass lasakdion.has been prolieasionally iivatallW in this Home
kD to provide the following Qt owl performance..
m -- ---Job hlome: Mandaeina — _ Tract: #28719 Fle�n tl: �C — hese:
ao Cell)eg Area:1t-38 Blows LLsulatkm Gavage Ceiftg: Pion Aams:
Q With.lAvbz Above _ ..... ......_ & Ste plag A�ress ....
_j
D RxkTk[r W11lsr R-13 Unfaeed Batts Accen Attie:
W— --- — _._..—...---- — -
W
Z Interior Walb: R-1 I Unfaced Batts
Settees Floor-
0
Q Subcon&actor.. Oj Insaladenl Co., Inc-
4M2ti Redo, Tenteeota, Cs 9MO
o Sued
N Ions Berry, Cenerat er- Temecula Brench
0
It -means resistance to treat flow. The higher tiro R valae, the greater the insulating power.
Ask your builder for tke fact sheet on R- values. Keep this ceniticate with your other
r , valued papers. If you over eel) this horse, this c allScate shosld be passed cm to the buyer.
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05/24/01 THU 13:19 FAX 760 7727193 JON TANDY X011
JON TAND.Y
Y
V= dj" hire.
palm Desert, CA 9 211
office (Iso) 772-7192
I C E, Fax (760) 772-7193
Pew (M) 7764336
REC43TMED INSPECTOR'S VVEEKLY REPORT
TYPE op O REIMFoltem CONCRETE XSTW=. STEP.L ASSEMBLY 0 H Q p
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CERTIFICATION OF COWUANO
I MEwTVE -MMTUOD
IIOTEQ IMA1IE pQ M TIaS WMK TO COMPLY YIIITH THE APPIIOYEO
s'...SwP.EC'4.F..�Jw1.TtOiLS ANO ApPLCABI6 5ECTIKM OF THE OAF ffi QFVMY twoulp mow wcw