9905-340 (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
i%ryy ,//DateDate + ,,!Signature of ContractoI )'A
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 mai6tain 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.
(ti),/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.
S 1 XfE+ M-4) 06,26355-93
(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>rshould become
subject to the workers' compensation provisions of Section,3700 of the Labor
Code, I shall forthwith comply with'those provisions. 1
Date:d� / L` )i 't Applicant
Yf; r
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
perntt,.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. ldagree to comply with all City, and State laws relating to the building
construc4on, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent)-' !_ A•-- �-+V Date/� /
BUILDING PERMIT PERMIT#
DATE VALUATION LOT "05.340 TRACT
05/27/1" $108,613.40 125
284159.2
JOB SITE
APN
ADDRESS
7&513 SAN MARINO C'iti.ilt�
609-070-038
OWNER CONTRACTOR /DESIGNER /ENGINEER
ADVANCED DEVELOPMENT CORP. 'IRADITIONA.L BUILDING rQ .!.NC
78-615 NAPLES Did. 78-615 NAPLES DR
LA QLUI1TA. CA. 92253 LA QUIIV3 N
CA 92253
(760)772-02222
CB # 5750
USE OF PERMIT
7f , 'A k411 Y INIum Ii►.i
SF"D - LOT ��5, PLAN 2A - PFJ MiT DOES W)T CNCUME BLOCS WALL
OR POOL. PLAN CEi1?GTr PORTION OF FEE RFDUCED 75% FOR NILTLI[PLE
fSSUA,NC"E OF SAIVE PLAN TYPE
lRACC CONSTRUC1`ION 1,834.00 SP
PORCIi/M.10 :6.00 SF
GARAWCARPORT 409.00 SF
EXITMATE.0 COST Ori CONST RIiC.'�` ON
108,613.44)
P7ER119-9't'FEE: SUMMARY
CONSTRUMON FEE 101-001-418-000 $671.00
'PLAN OMCK. FES: 1:01-000.439-318 5138.86
NiFC11.A.NICAL FE101.-000-421-000 $47.00
ELECTRICAL Fn 101.000-4211a W $120.t;'7
PIARVIBINt1 FFE 1.0'1 -WO -419-000 $131.75
STROM MOTION FEE - REESID 101-040-241.000 $1.0.86
GRADING FE1i 101-000-423.000 $20.00
MF1iASTRUC1`` RE FK- 225-M-443.342 $2,421.06
XRT IN PUBLIC PLAMS S-RESIU'701-0011-255-1100 $21.53
SUB -TC,'" CAL CONS' I RU("'! ON AND PLAN Cl-1;FCK
$3,58$5.93
LESS PRE -.P r) FEES
$0.00
TOTAL PERMTT VE&S DUE Ni OW
$3,585.93
4 P�_
-R CR
ATE
BW
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
7
Combustion Air
Roof Deck
— — (',�
Exhaust Fans
O.K. to Wrap
9-13 g C&
F.A.U.
Framing
�_ l
Compressor
Insulation
/ Z —95; 49 4z—
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
—2
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
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final Z
Utility Notice (Gas)
ELECTRICAL APPROVALS
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
Final2—
Utility Notice (Perm)
DEC -20-1999 15:5? WESTERN INSLI-ATION 909 586 8786 P.11i18
UT STERN INSULATION, INC.
4211 Latham Street, RiVeraide. C oMinin 92soi
(9091696-876c).
(909) 686.8766 Pax
INSULATION CERT FICATE
THIS IS TO CERTIFY THAT INSULATION HAS BEEN INSTALLED IN CONFORMANCE WITH THE
CURRENT ENERGY REGULATION, CALIFORNIA ADMIN:!STRATIVE CODE, TITLE 24, STATE OF
CALIFORNIA, IN THE BUILDING LOCATED AT:
TRACT/ PHASE: BELLA VISTA - PHASE 1 TRACT #:28457-1
LOT#: 25
SITE ADDRESS: 78523 SAN MARINO, LA QUINTA, CA.
EXTERIOR WALLS:
MANUFACTURER. JOHNS -i ANVILLE THICKNESS: 3 5;8 R -VALUE: R-13
CEILINGS ;: �AS BLOW
MANUFACTURER: JOHNS -MANVILLE THICKNESS: 13" R -VALUE: R-38
-CEILINGS: BATTS �O
MANUFACTURER: GREENSTONE THICKNESS: 103" R -VALUE: R-38
GENERAL CONTRACTOIt:
LICENSE NUMBER:
BY:
TITLE:
DATE:
IN ULATION CONTRACTOR:
LICENSE NUMER: 48127$
BY:
TITLE:
DATE:
il
ER 20,1
r
ROCER SNELLENBERGER
WESTERN INSULATION, INC.