0101-189 (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
714188 B , 1 COW(
�; r0 r-1 )l /AAsr t / r >
I. I/
?P Signature of Contracto/ 41 j � ,yam �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 ),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 Y y/ Yy;1 yyhip rr�� tr�,y�I� Policy No. ygyh ! q ata �' �r�
A��">1,0,104 l4r�iI�P�& 1 :74a. J'6 dT!Fe�•rY+�'C•✓ 44- !2
(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: f�• a # Applicant - + 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 f
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 ati
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Sie nature (Owner/Agent)'L-:� .x '' r Date
i� BUILDING PERMIT PERMIT#
DATE VALUATION LOT 01,01469 , TRACT
7 > 24317-1
JOB SITE
APN
ADDRESS
9t -4W CAN 7r. 4 1 -Y
OWNER
CONTRACTOR IDESIGNERINFER
CMI'Tr L:AMWVaevovd4Ilyr)
Ca -M URY llt4YYd, v4AtiTw1IEZ
1535 M ':i?' WIR1 r, ', U9, �0200
15:3.; 80. "17' &.1 UZT, =I. #200
SAW D.�11�.�tt�AEY.i;9i' O Citi V2408
►1.hiW AER MARDT90 CA 92A08
.(909>381-60M CI Aft, '14120
USE OF PERMIT
SIM W"n, Yr VIVVEL1190
Irl) 11AN, 3X4 A L, T'07- PERMITDOW NOT 1NIC:LUrIrd.
btlOG:KWALr,>t€'tiroVIDRtVEWAY APT ROAC:t , M/a 1'i.uf N CHECK FMS
id�°1 UCTION POR IdUl.,' WLEJ.SSll A14C F- OF;;AIMEi
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
_
Underground Ducts
Ducts
Slab Grade
�7/p/
Return Air
Steel
Roof Deck
_
�j// /Li//�/L
CombustionReturn Air
Exhaust Fans
O.K. to Wrap
Framing
Insulation A
?� D/ jL�.
? j_
F.A.U.
Compressor
Vents
Fireplace P.L._
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
_
8.51ot.
—� -
Final
Final
_
POOLS - SPAS
BLOCKWALL APPROVAL.;
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to.Cover
Equipment Location
1
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING
APPROVALS
Gas Test
Waste Lines
.j��1J (O / 6 N
Electric Final
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
��3a�o/
Pool Cover
Encapsulation
Gas Piping
Gas Test
_
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL
APPROVALSG�—
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 "
Utility Notice (Perm)
Certificate of Insulation
Your Home has been insulated with CertainTeed Fiberglass Insulation products, which are designed
for today's safety standards and tomorrow's energy requirements.
Fiberglass is inorganic and therefore permanently noncombustible, so it does not have to be treated
with fire -retardant chemicals that will likely lose their effectiveness over time. It has not been treated
with chemicals that can corrode wiring or metal. Fiberglass will not absorb moisture nor will it
settle over time as may other insulation materials.
This also certifies that CertainTeed Fiber Glass Insulation has been professionally installed in this home
to provide the following thermal performance..
Job Name: Canterbury Lots Tract: 24317-1 Plan M 3A -ALT Phase: 4
Lot No.: 7 Job Address: 79-400 Canterbury - La'Quinta, Ca
Ceiling Area: R-30 Blown Fiberglass
Exterior Walls: R-13 Unfaced Batts
Signed
Garage Ceiling:
With Living Above
Non Access: _
& Sloping Areas
Overhangs: Access Attic:
With Living Above
Interior Walls:
Subcontractor.. OJInsulation Co., Inc.
42620 Wo Nedo, Temecula, Ca 92590
Tom Berry, General MalWer- Temecula Branch
Between Floor:
R- means resistance to heat flow. The higher the R- value, the greater the insulating power.
Ask your builder for the fact sheet on R- values. Keep this certificate with your other
valued papers. If you ever sell this home, this certificate should be passed on to the buyer.