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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
714188 D
Date "/�••- /,->_")__ Signature of Contractor ! � �� �� l�,•1` %
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).
( ) . l,. as .owner of the property, am exclusively contracting with licensed
contractors to constructsthe 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.
(�'tr I have and will maintain workers' compensation insurance, as required by
Section 3700of 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.
(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
Zcle, I shallvforthwith comply with those,provisions. • �� f
a ate: ZZ �•t'Applicant l , �_��G �r E f =(% ✓
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 thelabor 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
the above-mentioned property for inspection purposes.
Date
trSignature (Owner/Agent) �✓` ,�
BUILDING PERMIT PERMIT#
DATEy.1 VALUATION LOT 1:9..1.—.r�.15 TRACT
P1 is/19
JOB SITE
APN
ADDRESS V 59(y D /. g
765L4.9-04)41
OWNER
CONTRACTOR/DESIGNER/ENGINEER
t" ITURY CkL0,19X.L. CMd1FdWrIES
(,.Z�i URY CRnWW. C:OWAVI i'.4TES
1535 010, a 'Ta0200
1535V0. IV MR= M #20(1
aM BRR MARDWcO. OCA 924M
SYMI DEP,.1s3:AR—DING CA, 92 406
(90Q.)381-6007 CJ3iR .2320
USE OF PERMIT
�'"� (lig• 1��Y' ��1a1~.3��C�
LOT 9, PIAN aB; SFD , R)',.MIT DO.tf�l NOT 1T6C3.UDE 81.,taf; K LI►'.�r LA.%
00014 O.8 DIUV rV[fAY'.Ai'PRC,Jr CH, Pr 4 cHiri: WE F.tP±l.`Ii3aw -7s% mit
MULTIPLE 3SSIXT ANCE OF SAME PLAN TYPE.
CU21TOM CONM..?tt)C"! ION 2,497.00 3
P0 CH/PA.T16 218.00 RF
GABA CA09POR T (SX') 11;R'►0:09
,' 11.E RU. WRQ• .
CONSTRUCTION ME 101y000-418-000 000 $1,049.00
K.KH clf.ccK me 101-M0,439-318 $211.16
MECH.ANICACt 1t4's 9 101-000-411-000 SP LOd
iii .C.TPJC,A.1,WE id1'I°'01+70.420-000; �lP4.tTfl
PLUMBYHO FEE $168,40
STP•LL3NO MOTION PEE -12 ID 101-•000)-'241. $21.70
CIRAIDWO FFR . 101.000.42,3-000 $200
D4aVF1,0PZR 9APACT FEE $1,907.00
ART 11;3 PUBLIC PLACES r KEW, 7001-M7.255.0300 $4146
' 8�yyy�� s� �/y�)'g �e(s�q,L}ty��at•y 7 y+/ ����yy �} 7���y .r«,�g•�� �+� (
�.i,f�'�'J.�.7.kAL aan4JAV�.7i,13.Ur'. ,Li.0,C� .EI.i D t"�rd9.[Y '�.•L�L�iW-K
.18019 TIRE-FADD IME S
PAID
$0100
TOTA,14MUM ' W DUE NOW
DEC 12
1 .
_200D
14 U! LA VlWW
RECEIPT
DATE
BY
D IOL D j:]INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings '—
Ducts
Slab Grade —Z p
Return Air
Steel
Combustion Air
Roof Deck p
Exhaust Fans
O.K. to Wrap �d
Framing j)
F.A.U.
Compressor
_
Insulation // -
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath G
_
Drywall - Int. Lath 71 -
_
Final FL
BLOCKWALJ- APPROVALS
Final
POOLS -SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines 00
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral / _ /
Sewer Connection �-2 (�
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas) rNAPPROVALS
ELECTRIC
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
FixtuFes
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
---- —__—_. —Your-d�loitae-l►as-boon-i�e4ulated-with-�®rta+nT�ed Pibex�gt�s-insufetlon-products,-wt�ich®re_c�igtsed-__---
!br today's sailtty standards and tonvotraw't eneivy mquirements.
Fair tasa b imrgaaia and therefese permawr* noncombustible, so it does not have to be treated
--------- -- ------------------�-vatdif�tat�am-ehemic�ls�tt�t-wgl-l@eeiyt�t�ireiFertnreaess-���m$.-R-loos-entboes-Rt�csted-------- ---
it with vaherinicah that can omrodc wife or nidal. Fiberglass wdl not nbsotb moi%Wm noirwig it
--
H
r--
Q ilaterier Waft- lit 1 I Unlaced Baft Between Floor:
F--
,Snbeen�►�r8or.. O.► Insuladon C.P. , hm
z
42628 t Neao, Te>.r� +neo
Toin Berry, mineral Ma er- Tenwwfa BranCA
R- means cegistance to heat flow. 7be higher aim R- value, the greater the Walating power.
Ask your builder for the fact sheet on R- values. Keep thls certificate with your other
valued pias. Ifyou ever sell this home, this certificate should bo pLwd on to the buyer.
Ths also a-.gxtifres that CoetainTeed Fti1w Gfins ittsul'atEon bas been refesdonatty installed in this hoffie
io provide the foilowin8 thermal per4ommnse._
--
Job Rome: Mandarlus Pian tl_ 2.B
Phage: 3
-- -----
-- Lot Wa.: _.9 Jas dress, ys —
---. — —
—
°4
Coping Ares: R-39 Blovm insulation Garage Gelling:
Non Access:
With.Llvlrtg Abawe. ...........
.. & lopiiog Areas - - -
U
LU. -- -- --:. _ _._
-------
Extegior Wailsr R -I3 QyIkeed Bsais
-.. ------------------------- ---- -- (Dverbe -
�a ®late: _ -
------ --------
w
WiltlrLte9ngAbove
r--
Q ilaterier Waft- lit 1 I Unlaced Baft Between Floor:
F--
,Snbeen�►�r8or.. O.► Insuladon C.P. , hm
z
42628 t Neao, Te>.r� +neo
Toin Berry, mineral Ma er- Tenwwfa BranCA
R- means cegistance to heat flow. 7be higher aim R- value, the greater the Walating power.
Ask your builder for the fact sheet on R- values. Keep thls certificate with your other
valued pias. Ifyou ever sell this home, this certificate should bo pLwd on to the buyer.
05/24/01 THU 13:18 FAX 780 7727183 JON TANDY
JON TAN® .:..
Q Med0ol AV*'.
Palm Deo@M CA X11
of oo (700) 772-7192
IF" (7610) 772-7193
Pager (760) 77
REGl.rVMRED WSPECTORT WEEKLY REPORT
r " of o RONFOMM CONCAM - -swill A$$QR My v Sti o
Flows O POST TV964M¢Q MOM 4 0 AS %u'f POTHER .a
PERFORMO REIMFORMMASOMY 0 ARE PROOFING V)e- LOW (.-,-
ON IDrAT1DN 47 9 _IS -1 D �A 16 ZI-I
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romm
DAY Of WCC '
NATURAL( 1y
AMWWT
4,MwMWwVAWM
b/S CNAiIND
A.' 1 •
MRS. CHARGED
DA7fi C�2 VA2 . . L SWSt
6;,/ Jg s i` Lod ".)a 4i-3 6- 04 ®A Jw. l 14
0" SENT TO CLIENT O
SCMT'INUBD ON NEXT YALE p PGE OF
CERTIFICATION OF CO M?LMNCE _
I HERESY CERTIFY THAT I HAVE INSFECTEpp TO THE BEST OF MT`
KNOWLEMALLOFISCEASOVE RE D p $
� OF MOTE�Sena"
- GT�NOTED.I HAVE vuAoTHIS WORK TOCoaPLY WIT" THeAFFMVED
PIANS.
SYECIFICATIG $ AND AFVLWASU SEC"OKS OF THE