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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
C`. pter 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
eZat%' Signature of Contractor' ^�'�'°"rj)
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
Sectian 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.
l"COLDEN ZAGLJE WS, "Clw, OWN
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(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
sub' -ct to the workers' compensation provisions of Section 3700 of the Labor
C de, I shalltforthwith comply with those provisions. '"I
ate: .: �,/i ��i, `x)Applicant
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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. Lagree to comply with all City, and State laws relating to the building .
construction, and hereby authorize representatives of this City to enter upon
the bove-mentioned property for inspection purposes. 1
Signature (Owner/Agent) N •?°1./tt'' 4 Date G
BUILDIN PERMIT#
DATE VALUATION LOT O;f;x••: % TRACT
qDp It ray
JOB SITE
APN
ADDRESS
7C&-490-042
OWNER
CONTRACTOR/DESIGNER/ENGINEER
CE..�J'li.1,1K Y c"12O4,11'O-L CO1+aiWNt ARS
MN(T'URY C:7d.OWET L C(Yib M'(.1)THW8
Eel. M. 420fa
151351115C), NFL #Zoo
8.AN BIN,—W RDIND CA 92408
SAM BERNARDIN'O CA 924.08
�1?CI) S1-ti0!)7 MIA 2120
USE OF PERMIT
1 O r to, PLAN M, SYD • PRIZAA)T OOPS NOT !K1 -i 'L1 DX` BLOCK _rA:t LS,
P001,q Ort DRIVEWAYA1PPRO!'#t:°H.
k t7ii,:TIPLE ISSUANCA, OF ,AME P1 -A18 i. YM
CUSTOM +^O17�`,C UCTION 2,SY7, 09 Mn
PORCINPa9s'1` O 21 100 se
0-AR-AmucARrORT (n) 1118A05
Esli <YeS.k4,'k]ro cogr Or, CC?mi""rR1Ji.':i ON
216,9W.90
PXiM 4 P&t'is fAMMARY
COMSTRUOT10'114 F.M. 101.000-41e-0€ 0 $1,049,00 .
PL,AH CHE-GX" PirZ 10'1.0,00- 299.318 $312.16
MECHA?MAL E 101.000.421.000 $91.00
101 rOO -Q""1,0 C'i3li $144.0
,
PLUMBB40 "It? 101.000.4I9b000 $168 50
S'i'12ONO MOTiO14 P"iZ • R.010 101-000-241-000 $21.70
ftllt A#yR40 Kfe, 11131.000.4.2? -000 $20.09
1v3EVEWPER ImpkeT FELY $1,9f?: 00
AAT [N PUBLIC P'I.+ CEW - R&&S'IE 701.000.255.000 $42.4
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�I -TOTA% , CONUTR%i1C"'I;tM4 M) PLAN CETC`.3.�'.
$3,655.12
1=1 ME -PAID MRS
$0.00
DEC 12 200
RECEIPT
DATE
BY �'
DATE INALED
INSPECTOR
e. //
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings 791
Underground Ducts
Ducts
Slab Grade
Return Air
Steel_
Combustion Air
Roof Deck _
0. K. to Wrap _ I _ p f
Framing LIE—
Exhaust Fans
F.A.U.
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath% p4
Drywall - Int. Lath
_
Final�� / ��'
BLOCKWAL APPROVALS
Final
��
POOL7S,/SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines Z Z p
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral / 2
Sewer Connection
Pool Cover
Encapsulation
Gas Piping
Gas Test �Z
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.
Smoke Detectors
Temp. Use of Power
Final _ 2
Utility Notice (Perm)
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R
Certnicate of Insulation
_--.— Yoar�iatrre-iras_�een insutatcd_wifb �estaiw'd sed Flberalass las�+latio�►rodoels.--
fa tod$3Ps safety stendartb 4ad twnomvvra enorgy requlreamm.
Pibergiess is iao4anic and Herefore pernton ndy stoncomiutstibie, go it does not hrm to be treated
_._..... _-- .—.-.---._-.-------------..vrieh-9tra-r�stardec�che�ice�-wilLliloai�loce-their_et�cttv®es�ovrr time.lt.�_®otb?�d
N with chanicals *a can eormde widng or mctaL Fj"cugfm will not absorb isoi3tura nor %vU1 it
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r- This oleo certifies tient cermInTecd Fiber Glens Blatta has beers pmfessionaliy.tastaltedm this home
to provide Ora following thew! jorfORnaaca.-
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_ It--JohFAdtlreaa:-?M00 Baia gtmet-- ---- — — --
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Calling Area: R_39 Biown-Insuladoa GsraOe Ceilhrg:. Nan Ate:
With riving Ahmm .!& Sloping Arems ..
Herter Wash: R i3 Unfaced &alts
Overhangs: Aoeras Attu _—
Ld-- --- - --- — -- — — — ---- — — — -- — — -- --wits iidong "ove-- — - ---- --- ---- — — --- --- ---
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Interior Walls: R-1 I Unfimed Batts
Between Ftoor-
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SNbcnntiractor_ 01 fnsulaw" C,e , Ian
z dill Teamata, ca lime
o Signed
Tarn Berry, General Mate T'emeada Brauer
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R- means resisinnce to heat clow. 'flee higher the R- value, the greater the Insuladog power.
Ask your builder for the fad sheet on It- values. Keep this certificate with your Other
valaed papers. [fyou ever sell this.horne, this certificate should be passed on to the buyer,
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03/24/01 THU 13:18 FAX 780 7727193 JON TANDY
REGOMWO INSPIEC M'S WEMY R EPOW
TANDY
37630 U801001 Ave-
Pem DesoM CA W211
oiiee (760) 773-7192
FOX (760) 772-7193
Pager (760) 77338
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TYPE OF 0 REINFORCED CANCRET6 XVIAUCT. BTEEL AGBEMGLY
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CERTIFICATION OF COMPUANM
I HEREBY CERTIFY THAT I HAVE INSPECTED TO TME 0E�T 411
,uOmEDGE ALL OF TNEABONE Rmmo 1A m NML6SS OT1Kkw�i
mom I MANE FOUND THIS WORK TO COMPLY MRtN TNp APPRQVEp
PLANSSPE WAT10ME AND APPtICAWA StaC aS OG Tttfi
.....e e..w s... ter.. A-0
RE of Aramam O&ECTOR
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