0011-253 (SFD)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
'rofessionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
118 B
/ate X7'7
—79 ,Signature of Contractor J0G �`•'
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.
(7 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 EAGI,Zt '11433. 7�iVd C•59�iUfifs•Kt �
(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 provisions.
"Kate: r'. �f`/,:�1�.°7r Applicant �i1 k� "1 77 A< ., .
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
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) +- vu ; -t `-r Dat " f `�
BUILDING PERMIT PERMIT.#
-C
DAT 1140)►^D VALUATION LOT �1��'�� TRACT,
2wil 19
JOB SITE
ADDRESS
APN
77:' 0WO BAYA
769490-042
OWNER
CONTRACTOR / DESIGNER / ENGINEER
CFtWrUR Y' CROW=, C0W&W1'1'!ES
CM'iiRY CRO'WJML (X)M i.U�"1"1�.,
15.1450, "1%IY2 g'Tj tlt1
1555 30. V umn- ,1"17.10200
8W laiMMARIDI%AO C.A. 924W
114.1 P + cN . WO : *CA 924.08
'(pni-6007 CBL# 2120
USE OF PERMIT
�'CL� �.r�1�VL•Y 17�a1%Z.D�.,li'3'E�
LOT 6, PLAN 113; SPT,'. PEW IT DOMNOT IXC.1r'UMF SLOC;I: b°JALLS,
P0014 Oft. DRIVF.WA.Y' A!aPPP.0A(;EI
CUSTOM CONIJTRUC-TION Z4.19.00 OF
POR.CHIPATIO 200.00 sr
CARAMICARPO T (OF) 11,383,00
• "I-�IC'?iiiC31
G3se
?p24Wd47KD
PyM1RM" 1V7dmy
C 0140TRUCT10?4 RE 101-000-418,f000 S410010
PLAN CHECK pry, 101.000.439.318 !�So29.15+
M9CHA231C'A'L FEE 101 �-000 421.1300 X34, b
FA&r, 'RICAL-IEN 1014=420-000 $1a9.'ii
PLUMBING FELE ' • 101-000-419-000 U62.50
STRONG MOTION FEE • RESID 101 -OW -241.000 $20,25
.43RM)INO111,11)✓ 101-000-42-3-000
DEVFADPE IMPAC`Y Irl? 'x�,�t►7.r�s,
• ART IN 'PUBLIC PbAC' M • 'USIC 901 ^0009 255.000 �1R,UCy
f
b
ID PI.!'+N 0MCK
$4,15:3.21
)CONMROC110N
DEC 12 2000TaT* lggmfC :Es DUE 14OW
�0T Y tit -
DATE i<
BY
DATE
DATE FI ALED D
7 7Z
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Z47Underground
Ducts
Forms & Footings
Ducts
Slab Grade
_ d
Return Air
Steel
Roof Deck6!
O.K. to Wrap
Framing
Insulation
Fireplace P.L.
��
....��7�-� /
`�
—`—,
`
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fireplace T.O.
Fans & Controls
Party Wali Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
MIKE—
_
Final
BLOCKWALL APPROVALS
Final
� 2
POOL'-;3PAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
12-0 7—pp
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Gas Piping
Gas Test
Appliances
Encapsulation
Final
COMMENTS:
Final
Utility Notice (Gas) i
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service 1-01
Sub Panels
Exterior Receptacles
G.F.I.
_
Smoke Detectors
Temp. Use of Power
Final i
Utility Notice (Perm) /01
14
-----�1Com'��orna-pias-0e�rinsnSated�with �i�sT�ead Fiberglmuinsuiatlorrgrodueb;-wGicg�at�tiesigned- -- ---- --- -- for tows safety standanis am tamoeov a energy reVWemenw.
Fiberglass is inorpnic and tberefen permanently noIu;ombustible, so it does not have to be tr+mated
-- - ---- �- ------ with�it`�3+etteh�slat)rat�rilTldc�6�los�tl►el�e�ti�oDegsoveatlner�)tt-ir�natbeeatteatEd---...------------------ --- ----
wfth chemiraals that can corrode wiring or mctal. Fiheagzs will not absorb moisture nor will it
----------
m
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This also cadifles ilwt CerWn'> 6d Fber Uhas-insub9on has hcch profmioos* hawlled in this home
o
-
- - - - --.--- to provide the foUaiyiogthermul perf6maw-
Or'
Job warn. Mandarlea Traet#28719 Flay #:111
Phi 2
-
- -- -- -
- -
i
Lot No.: 6 Job Address: 79-.%Q Bays Street
-
u
�
Ceiling Arac R.-38 Bloym Insuhtion Garage Ceiba$. _
Non Ace=:
Above
Sloping Areas
W -- - --
Rxkdor Walls. R-13 Uoefao�d Batts
-- ..
- - ---- - -- --- --- - -._.—Qverhanoi, --— - -_-
A ftk -
�
- -- -
W
-- -- --
With 'UviHg AboYe
W
z
Interior Walb: R-1 1. Unfaced Deft
>(;etwcan Floor: —
0
Subcontractor.. OJ IMUlation Co., Inc
426VJ Wo Nedo, Temecula, Ca 9M§
o Sped
N Tom Berry, General MW'er_ Temecula BOMIC%t
m
m
R means resistance to heat flow. The higher the R- value, the greater the insulating power.
Ask yaur builder for ilia fact sheet on R- values. Keep this oertificate with Year other
valued rapers. If you ever sell this home, this eertifcate should be passed on to the buyer.
v
N
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110
05.'24101 THU 13:16 FAX 760 7727193 JON TANDY
JON TANfDY .
37M Ueqool Ave.
SAS DeeeM CA 1
Office (760) 772-7192.
Fox (760) 772--7193'
Pew (M) T76- •.
1� 005
TYPE OF o REIMFORM0 CONCAM XSTRVCT. STEELOSSUMUY a S jo (r
INSPECTION O POST TENSIONED C01NCRM f13 ASPHALT ?KOTHER + t�
PERFORMCD O R 0
EINFORM VMQNRY 0 FIRE PROOFING I` (�•
CERTIFICATION OF COVAPLIANCE
1 HEREBY l�EtI1iY THAT 1 HAVE INSP6CTECp TO TME ilEST OF MY
WOMILEGGEA110FTFIEAAOVE I&PDRIiD1VO�G<NiRESSOTNEAVI�E
NQTE-R I KAW fouND THIS N+ORet TOeQ W"r WITH THE APPRQVW
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COPY SENT Tp CURMT 0
OOM4NUEC ON "W NAGS 0 PAGE OF
CERTIFICATION OF COVAPLIANCE
1 HEREBY l�EtI1iY THAT 1 HAVE INSP6CTECp TO TME ilEST OF MY
WOMILEGGEA110FTFIEAAOVE I&PDRIiD1VO�G<NiRESSOTNEAVI�E
NQTE-R I KAW fouND THIS N+ORet TOeQ W"r WITH THE APPRQVW
PtAIrS,sPEctPICATIONS AMG AW"W Li OF TME
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TU AF i1G(stSTiR[t� PR
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