9910-193 (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
69'7.'t 1'7 14 10)11/201
\Dte 4J 4e4 Signature of Contract
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).
O 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.
S1KA.C' FLO'IJl.) l ~ Yl•�1J39V.E1N
(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
Code, I shall forthwith comply with those provisions. - f
DNte:.�f Applicant;r� ��r---
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth. on his
application. .
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, &,shall, indemnify
& hold harmless the City of La Ouinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null.and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Sig lure (Owner/Agent) Date_4V_ � ' 9\t U.I
PERMIT# .
BUILDING PERMIT��-��
DATE t j t VALUATION SJ,31Spt51C➢ 49) LOT(p�1 TRACTJOB SITE
k7S953
ADDRESS 44-795 S�S►1�TA BEa k�A APN
g,,L'�1.r�..�. 604-392-M.
OWNER CONTRACTOR/DESIGNER/ENGINEER
OL;.1'li.r?NIN"ANDWILLIAMS ASSOC, WC. 01-11'`F1.AIePY'A.t+fbWi•L9:1, MSASSIIX,.%ENC.
77-M AiTE:NU • OF THE S £diTES 77-900 AVENUE OF 'l IE STA:M
PALM DESERT CA W2211 PALM DESERT CA. 92211.
f:M�stS}3$�..7.6'?6 r'1:$Sfol g1�3
USE OF PERMIT
SIWILE 1~.AMfl,Y 'ir.:lWr-.Ld..]`MG
3 -so- LOT GS, PLAN 3A. PEitlirIT DOES W)T 1W 3X1DR BLOCK WALL OR
K.Kill-75% it.EDUC;Tttil`i'FEE ON' &111 1PL.E i.SSUAI C`.fw o 3AN1s 1E3, -UJ
Typf'
b'<)1101/P:+.TIO iZ0.6�D ,s3T
GARAO.WC ARPOWr
%15
S, Kfd���$1. bJ.�V'MOFYl ��"\✓WIVS9,R.�LUCtl. J��V41'�' �
� S�.iNV�.y�s��
PKRMIT FEM. RY
�;�:s1<.MRI.0-HO1 FRI
101-000-41"00'
PLAIN C`ftE.f;°fe` TOTS
101.4)00-436-315.
MECHANIC, At. FTE
101-000 X92 i -COD
.�4
fAACFWCA1, EM.
131-000-4104i0i?
P-L'U;i�iuwo F3.. -F
101-000-4194W-
STROW4 M PTI ON rte, - RESIN
i { .1-000-241-f?:tt) •
s1 -_i,
<w
C6YiADINI G A'S,wE'!'
t.
DEVEIA)PER. JA4PACT FEE
ART IN PUBL IC I LA(.,ES-.RBS;.M 701-000-235-M
1 �...t
SUB-TV)TAL CONSTRI: �c:: TION AND PLA. N CHECK $3;362,59
LESS PRE.-;PAII3.PEES $0.00
'G UCA11 P :RM.IT V•ICIVS Wir, WPM
RECEIPT DATE I BY Y;�� I DATE FINALED I INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
IT
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
i - 14
Exhaust Fans
O.K. to Wrap
_' p- `L,b
F.A.U.
Framing
.l 3 _
Compressor
Insulation
Z c�
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wali Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final I
_
M3,1 I�
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
�.�Q� �'C
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
2-%'O
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final (.
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
Final
Utility Notice (Perm)
Certificate of Insulation
Your Home has been msulated with CertainTeW Fbe3gaw Insulation, p<io¢ W% which ate designed
fbr forms safety stattdants and tomorrow's muff Mvi- et .
Fiberglass is inhr ica id thenefate.p®anelilly norma sh 6o it dues sot bave to ire heated
with f M_ntU&,d dm nick that, will. Q* lose their effiDaw mess over time Ift bas not been treated
;.
viith chemicals ttiat`csa dorrode wiattg at metal �giass.wt7l.nnt si>carb mnim"e nor Wtl -A
settle ovu 4ime as in" other iamlatiiak materia & '
This also aeati that CerW#T edFibei G1xss jatiWetion has.beeu.pm eswonally iwM&d m this home
m prapide the following tbernta! g�orttt�oe;-. ' . .
rob .Nance: Sony
Tract:` 26953- -Plan #i 3,* pbue:. 3
Lot Na: 63 Job Address: 44-783 Cane YtslwBerbra,,La Quinta, CA
Celft Am :,R-38 Ui&wd. Garage Ceiling;
'With3d"W Above
Iaterlor_�i►aUa � -
;. .. rior Wells: A-13 ibdaaod ..
Party Wars: With Un-ftAbove
(2 lay ) Cohn AadiDer;e:
Slribcorwactor Ol.Irimh9don Co., 144
" v �. cs �� . «siva Lto'®r gae5709
Signed
Conch#a Or*j Secfetaryll'reamr* --or-- R S'co Jenldnst President-or—
Lou 1 erol4 Director of --.0 doms O, 'car
R means redstanoe to heat flow. The higher the R-wbw, the greater the kadating pavm
.Ask your budder for the fact sheet an R values. Keep this oeidficaie nilh your other
valued papers. Kyau ewer seU 9" home, this oertifimW should be gassed on to the buyer.