9910-205 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Ch2'pter 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
697.117 ►3 10; if WA
to 11 1V O Signature of Contract o
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.
`;7';1+U tVIV0 w6 a-.fiS► Ut3ailT t'�11
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) .1 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
I de, I sh h forthwith comply with those provisions
Da'3e: �� >L `� Applicants- -4K-le
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. r
Sig�ature (Owner/Agent)'� J ��'i' i�'� //(J- Date Yo d1
PERMIT#
/ :f BUILDING PERMIT :0i""440s
DATE
�' 1 VALUATION a ,LOT ! { TRACT .JOB �►�y� y Y�
ADDRESS t/4�-+ � �'�.�...�s.Y�� •.. GA .n Lit 8,kRfi1J'�.UA APN a➢ - - � J
OWNER CONTRACTOR / DESIGNER / ENGINEER
;fi.,.!.Tl )S�..1.fR' i4"1e 1001 1% 619dteil r u A RBti, A VM1Y-Vl IkIfl
L.L
X1. 0,;0h JA_..O C1 • _i..
PAI'm UE'SERT CA 92211
USE OF PERMIT
a)t 9a .it0A+t'AA" T.1L }dt't 3'
iti +au tv:lari.if'"'' 7trr.:,.
PALM k)F'N. 11 CA. 9221.1
CIR1.10. 5203
�;1'N�ss..E �'t�3v!l.i;i..tr� l:t6ft/�I;C•.1:�C�1a ; .
3u^'U. Lo- , ?B. -pow. f t .DOGS 140T Nt.""`1..VOE a3 OCR WALL 6R
V00L. 7iP/iaKQ)k1C1J0N,, F ;,8 ON OF SVIJIV113 PLAN
TY.I3..
95TI &TED COS .0F.CONSTRUCTION
PERNUTFE F, SUMMARY
c.e>td�°idafG"Y`(tiX� :P'9?�
l t11. ••(13?S!-Q 4 �-UfMi
$"/ a,t�i
-.�
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PLAN (NEA"K sit;
11014Xn-439-313T
fiAJY a'13DCA1, EkX
401-4WO-420-000
tri.iiAr113INOFiM
10i• -OW -410 -WO
sTRONQ nhcY4'.1<._bN TEE - RFS IP
10j. -ow -241-000
$?<t,�VM
r. AnI NG rpt:
tat-CthIOA23-OW
$20.00
A.Wr .IN Pt_,+' LiC PLACT-.S - .Itt!sEbW 701-000-:25.9-000
$96:3y
LESS PRF-t'&ID r -E S
10.00
RECEIPT I DATE I By \:,J/ 1 I DATE FINALED ' I INSPECTOR
INSPECTION RECORD
y OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
4 - 3 r
Exhaust Fans
O.K. to Wrap.
f t f_
F.A.U.
Framing
Compressor
Insulation
-
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
$ _ ao
Drywall - Int. Lath
-so
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
I -_00 bi(T
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Z - aj -
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
8- •cp
Appliances
Final
COMMENTS:
Final Lf 2
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) U w
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Certificate of Insulation
Your Hme has been insulated with CM=Twd.= lndWn-v&;b am&&Vwd
bY today's safety standards and s energy r6iionca&
is iso rgm cagdtherelbrepern4moully.so it d6;i" a have to be treated
wish & 98"M �ith" will ., ire Ah6rdMe. KIM no bumi treated
xd
0.
�77", Cqr.I6fk,-* fitbmglass will nut absmb mdsb=-jjcj. well it
sdffle, dy& ddte as znk— WiisulatUm rli�
yte
z.
This also certilics Ow CaWmTocd, F%q lliis Ips. beenC.
pra&mimWly insWW in this liume
.wApion
to pmvide rile IFPUowjng aterma']
•
Job. -Name: Sonvise Tib 25953 -Plam k 3,
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'Let Na: .7 Job Address: 44-800 Calle VU-ta Barbra. TA Quints, CA.
R-38 Unbmd 'C'
CMing Area: Garage alm
AD?
uftdor Wags.
darior.Walls: R-13.Vntacol
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Psuty Well Wits Lwmg°Above
Ln-.,
Ln,
M
CS),,
S"COOW&Wr..
IW&Vb .. 4 A.. C49AM,
Conchft Ord4 Secrdb6areaarer --or— A. Scaft-JenHwo Pmldenf—or—
Lori Merola, Director of Opera&ns 0
Wer
R- me= resistance to heat flow.. The higher ft, I.t- value, &C. greater the insulating pourer.A*
your fxffldw fDr W fad sluxi on values. Keep this 6cii a'te WM yaw oflbcr
vdued papers. if you ma sell this hme, this catifimie should be pused an to'tho buyer.
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