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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
116
Ate d� �`�'�� Signature of Contractor �"J!'�j;�r�
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. �, '
w TI -Arkp C�CtA'1r1134"T'T MOWN
(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
Code, I shall forthwith comply with those protio s.
Date: 14, "," 6 .4 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_w
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 prope2y,
or insp ct12l pun os'as. ,r
Signature (Owner/Agent) , �� Yr
3 >�A. Date
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BUILDING PERMIT PERMITN
DATE VALUATION LOT TRACT
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR/DESIGNER/ENGINEER
CIT ,1;3- :4'' (MOW M.".i":C3MtMUND-Im
(2ASyYRX1A,POOLS SPAS CIDP MAW "'0
). $,,J7 s`..�yy;•�1�",.'�.�.1q, , ri'.£�, oo
a St%
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(766 )340.90%) IMIX 3
USE OF PERMIT
Pi LXJaP.9 A3BQ..PNSI Z21.-584995..0%ARVS,8AMXR3 SHALL LIE 114
Ct3Uffid'?3A1'UXT SLOC K `ea AI& C=Y S4`.faND,Ai D,
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fILXN fuH3±CK.FR,f; 101-000-4:39-318
C CYRST'Rtl. CTI!GN 1VIR, 101 -000 -418 -OW
N.Es°t RANIC;M, FER -- P0011 101-000-421-000 00-421.000 $24.00
EL.F.CTRMAL tT - FK)01, M-000-420-00 $0.00
P1,113•I"011110 FFRI - POOL 101-000-419-0u() M OD
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APR 4 2001
Elle .
ANCE BYv D ALE / INSPECTOR
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INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wail Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
Set Backs
Footings
Bond Beam
Electric Bond
Main Drain
Approval to Cover
_ _`•c (�'
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas TestElectric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
Pool Cover
Encapsulation
l3lD_t'
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low V�ftage Wiring
Fixtures
Main.Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
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Certificate of Insulation
�Fo4tr-4lsaoebsg'been-iueuiated-�vitl6'C�rtaee�Teed-1<ittecgtass-Inaulatio�prod�setsTwhich-soe-deslgFsed-- ----- --
fOr todayts safety Sumavds and tomorrows energy te%immmts.
CE CE Satbcern graetor.. OJ IMUW04 6 CO., INC.
? r 426261 19 Nedo, Temeeota, Ca 9L"O
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Signed- l�
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Vara Berry, Gemml l gff- Temecula BrAwk
R- me ns resistance to heat Rowes. The higher the R- value, the greater the insulating power.
Ask your builder for tim fact sheet on R- valves. Keep this certificate with your other
valued papers. if you ever sell this home,' this certificate should be pamed on to the buyer.
Fiberglass is inorganic and thamlime petmanetztly nonmabustible, so it does mot have to be treated
— --- -'---
- -- -- -with ram-wAoml m-chemdcais-dntvdll ii[*rhedtoir-effec vanessvvertime.-lt-hss-aot-beeartreatcd-------.
with chemicab that can corrode wiring or metal. Fiberglass vM not absorb moisture nor Wal it
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ibis also eenifi s duct CeitainTecd Fiber Glaw lmtltttkm he been pAofesalonally insudled in this home
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to provide the follorwirg tberr ml perftm ance..
Job Pb me:Mandarins Tract: #287.19 Ptam p:3C Phase 2
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Lot Ne�: a Job Address: trees
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Ceiiimg Area: R-38 Blown Insulat om Garage Creiihtg: Non Access: _
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Wilh� Llvhrg' Above - - & Sloping Areas
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Raterior Walls: R-13 UafAced 139m.
_Ovverhan Acem Attie
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Interior Wells: R-11 Unfaeed Batts Between —
CE CE Satbcern graetor.. OJ IMUW04 6 CO., INC.
? r 426261 19 Nedo, Temeeota, Ca 9L"O
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Signed- l�
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N
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Vara Berry, Gemml l gff- Temecula BrAwk
R- me ns resistance to heat Rowes. The higher the R- value, the greater the insulating power.
Ask your builder for tim fact sheet on R- valves. Keep this certificate with your other
valued papers. if you ever sell this home,' this certificate should be pamed on to the buyer.
05/24/01 THU 13:17 FAX M 7727193 JON T.ANDY
REGISTERED MSPECMR'S MIMMV REPOii"1'
JON TANDIY,,
37650 MedjoW AVw:(j IIyy
Palm Dirt, CA 92211
o loo (760) 772-7192
FOX (760) 772-7193
Pager (760) 776-3356
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CERTIFICATION OF COMPUANCE
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