9910-206 (SFD)LICENSED CONTRACTOR DECLARATION.
��l 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
697111. 6
D to I / Signature of Contractol���,_�L{�a�
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).
()
1 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.
N�(�) I'have and will, maintain workers' compensation insurance, as required by
Se on 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.
`,'>TATE t! = 4167 ;99-M01,20
(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 1 should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Co e, I shall forthwith comply with those p ovI ions. /-
Dat , 11,14-)174 Applicant '4i,9- . - <�N. /4_ '
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.
�cature (Owner/Agent) - �s" Date 111 e ,-
PERMIT# _
o BUILDING -PERMIT `..0
DATE Y VALUATION S-k34,6�M SQ LOT � 3 TRACT 25953
r
JOB SITEi y i APN
ADDRESS ^e^ CALL TA .HJ. RR
OWNERy
CONIHAL; IUH/DESIGNER ENGINEER
iy,AS AS[U-`.! p1 ` -C,
-�INC.
AVENUE
PALM LFLIRTCA 92211
PALM DESERT A 9Z211
CA'
(710,0)30-24526 C33I<# 51203
_' •,,�h
-
USE OF PERMIT
4'UNG 1L1`AMTTLV O4p-LU-V
S '•
06. Ltd'!' B ULAN 2A. f E 'i' DORS NOT mak"•%.1.f0E 13LOC:€n WALL OR
11001,.75% 1:4Ei:PU011 f:t:3N F ON MMT WIX, .13SLIANCE OF SAME MAN
1' iA(-r CONST'RO-MON Z210.(V Sig
PORC0pli T'10 150.W sr-*
OAi1A.+: 0CAl'41,10 Y 648.00 SF
PERIMEE FEE SUMMARY
CiONST181iC .T10N FEF 1.01 -OW -41:8-M $762,00
P!, AN (.'rtppJqq': C ..K. FEE 11 11599.0
(11,f0.K/�30-439-3�{1�9
�8
fV.�.CJ\.Od:'1AYICA1l. 1' , 101-Ll4l 4121^000.
ELIEC;i'kt.tQ;P L FLU: $1474k
PLURNtYAfW!Fiiis' �i11 ti4D-X19-f iy11 "vttr9 15
a
{
°i'lY2C?NO W)TTr):t.D FFF. - RESVP ill 9-(W .$13.47
:.
tat;ADf7 ic.nmt.cit-cza13 d'2�I. p?pgt X?f1.40
., {
(:21„V1110PER (NWAt."'ti F L8
AFC'➢' !N Ptif3l:.Fv FICA 3wS 63:311 !(1$-t1 J� 'S5 4Jf3U W.75'
f
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.t:LI
;t !E-TiTCY1'.AL t.CsN�S'JRF.64-TION1 4ND PLAM (1HECK
$.'(,314 36
LESS PRE -PAD .FEES
SO.(M)
l'OTAL PERMIT 1+•EES 011JE NO
$3.314-36
RECEIPT
DATE
BY 4.J
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
�n=
Return Air
Steel
Combustion Air
Roof Deck
—tgp
Exhaust Fans
OX to Wrap
_2
F.A.U.
Framing
—10 0_0
Compressor
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 °t C
BLOCKWALL APPROVALS
Final
POOLS - SPAS
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
3, .-!
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection :
Encapsulation
Gas Piping
Gas Test
Appliances
Final
t
Final
Utility Notice (Gas) 7
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
Final dap �p
Utility Notice (Perm) Z qrj
COMMENTS:
r- —•
y
Cerfi-Acate,.dft,,-iIhlati.on
Your Home has been insulated with C dainTeed Merglass l iso atiea pmdwts, whish oze wed .
for tadWs satetY standards and tomortotv'B eaei r iegititw eats
Frberglaas, le �rnar�nic and tie perrnanemty a4nwmbavW sa it doea'ngt have -to be nested
with ire-rdardant.chemmcais that will.Iflm_I to rhea ,effed�[vene�.m�ea'bme tt hes not 1�eeoLt ed
Wlth cbemu-dls that i an oaitvdC !Anng Veli f 1m abso?bt� n 6r u it
setdc GmC bm ag mey 0ifie� iD6013hnII makriata t
Tws•aiw oeatif=that C mmnTead Fiber Glass Insulation has been p m fesaionalty installed in this home
Job-Nm=Sonrin Tract: 2SM PianM 2. Phase:: .3
La Wo.: 8 Job Address: 44-780 Cage-Mstm Ba!bM La .Quint k CA.
Cealing�Am-RAS.Unfa ed. Gail Ceiling
With I—AVbgAbwe
' Vxin-kw Waft: R-13 Unfeoed
Psety *alli: Wadh`Liviog Above
(z Nvers) - Ceiling Raft+em-
S�bcoA�r±®r`ctbr.. �, (illols Ca l� . .
'60D S: Vinod, "Asta� <3s 9]7U2 (67b)HIZ�(Yl0 , t�sflQ6b709
eohdifi6 6li4 Sk-retary/!'reasurer ter— A Scott Jea kiiS, President-or—
Lou,Merola, Director of 0peradtons.0fflcer
R- means resistance to beat Bow_ The higher the R value, the gmtar the uwWating power.
Ask your builder for the tact sheet an R. valoKzep ttus certificate with your other
valued papers. Ifyou am"this hoes. m% this oerdficate should be passed on to the buyer.