0109-028 (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
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
Date — Signature of Contractor
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.
.TrAT9 IaUN:O 1SY3l1 o�Gii
(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.
Date: 17 Applicant --J) u,fI �� �•
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 personat
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) �� - t -=> r-•�� Date!K— Y
dr `, . j
BUILDING PERMIT PERMIT#
DATE �ry i VALUATION LOT TRACT
J�'
4.90 0
Z 9f . b'�t,
JOB SITE
APN
ADDRESS
504 M5 C"IKO, rZtTVADO
777.Owa4 07
OWNERTT
CONTRACTOR /DESIGNER / EN (NEER
tTcy
RAHOM
F0 BOX 810
F4, -oxiv maurry'raim
,1.A QZT.I 1',CA CA. 92252
PRO, AZ
83034
��f+0 , sT�11i3 CE...i:
l 4990
USE OF PERMIT
SMILE R;1MILY TACHED
:rm.. Lar f)s 1'F. '?. PjA: !<''EXIMI'T I*FS NOT INCL. ID914.JZCX -WALL%
Pt,01,.USlmA OR DRIVEWAY APPROACH
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7:;ACF C0;�1+I; tt(UCZ ION V34A SI?
PORC4't61,ATIO 713.00 S?
NUMATED COST 0Y C'C?MMUTC310P'T
199II&M.90
CONS° RVIC3`y.ON FEE 101.000 41 B-000 5518930
PLAN CHECK VIEW 10'1-000-6439-11€s` $323.$?
41 FICHANICIAL FEE 101-000.421-000 573.0
M.,ECT RICA.L Meg 101-000-420-000 $201.30
PJAYMBIN01FER 101-1700-419.000 $19G.(►n
t mrRt Oiw3 TJtmioN FFR - Lt 1.1'5 101-000-241-000 l9.
` o31;,i#T,f@ SPE 101-C9T1r-4..23-{31309 $20.00
t �'Iy9$9.OG
1)7EVi_CU,OPY.R IMPACT nj1ZIMS
PRE -PAW PEW
$0.00
SEP 0 6 2001 'M i >VW �• z K S A NOW
CITY OF LA QUINT^ , s?
FINANCE DEPT.
dQ
:RECEIPT .., It
DATE
DATE//
f
BY
DPe FIN TO
!1 I ECR
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INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
�Q-i2—(J ( ,�
Underground Ducts
Forms & Footings
Slab Grade
/ /
f (,/
Ducts
Return Air
Steel
1
Combustion Air
Roof Deck
1�=�1_j _
Exhaust Fans
-i
0. K. to Wrap
F.A.U.
�_ �f 2_�
Compressor
XFraming
Insulation
�� ���
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
_
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
'
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
9 O1
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
,.)Sewer Lateral
Sewer Connection
_ _
- J � -
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
_
ELECTRICAL APPROVA;
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
_
Exterior Receptacles
/ t9E:_
G.F.I.
Smoke Detectors
�—
Temp. Use of Power
Final
Utility Notice (Perm)
INSULATION CERTIFICATE
This is to certify that insulation has been installed in conformance with the current energy
regulation, California Administrative Code, Title 24, State of California, in the building located at:
50-035 CAMINO PRIVADO, LOT 98,11-A QUINTA, CALIFORNIA
CEILINGS:
TYPE: BATTS MANUFACTURER: CERTAINTEED THICKNESS: R-38
WALLS:
TYPE : BATTS MANUFACTURER: CERTAINTEED THICKNESS: R-21
�• ,yOV
' i_
SCHMID BUILDING PRODUCTS, A MASCO COMPANY LICENSE # 632072
BY -7V FAI X -IVL( ff- /GZZ\ TITLE: ADMINISTRATIVE ASSISTANT DATE: 11/13/2003
S