9910-191 (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
ti�711 ? i E3 E e�%;y i!`34�ti
D\e 11;iof Contractor
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
peormance 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.
(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..
D l «J Applicant . v ' ,- -lam
e: �— :;! �_
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.
Sia ature (Owner/Agent)/% Date e
BUILDING PERMIT PERM T#
4�'.9.1.f1- � 71t1;
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DATE /q�{/ VALUATION $11717,6•."7�jo LOT 63 TRACT A-5953
{ 1 ►1
ADDRESS 44-845CjWX NA1.14677 BARBA
APN
OWNER
CONTRACTOR / DESIGNER / ENGINEER
!;vIF'x 1:"1"f". UMI.a—).,C.f
pr-����'051�.:.z
: 1$Z��
'1,7 -900AVENUE CWTHE
77-9CA) z`iYTNU8 OF THE �!'ATES
f'r1.LM. DUSM" CA. 9 22 11
PALM %?ESMT CA 92211
0r31945-20,6 ("D110 5103
USE OF PERMIT
S'il' GLF F'Alk IL DAWEi-.x.11 G
SFU- i3OT r;3, PLAN 4B. REMOI'T DO&S NOT WL;C'OR 9WCK WALL Obi
RA1XX.775P/0 RJ3J) C10N lrP%.0N Y14V..L T'IPLE A` A 45 O:F SAtMIG K.k'kf?i
'[W CTi:ONSTRUC I K L s SFS.+30 "S
TORO, :-ilJ''ii.' IO 70.00 SF
GAKAC WC—A,RP1WC SF
XYTHAVATFIM C-011TAW OF, CONSTRUCTION
PERMIT FEs L SUNb°QARY
CONSTRUCTION FEE 100-000-418-000 5737.50
P:f., AN C wilt: � ) f� e •.(�Q-� 9qD �y i � �w i ►�.taa�
AX-C'HAl+.`bCAL ME 101-000-421-000*
ELECFRICAl;
PI..t yfflING fW.
S1 ON 0 rOOTION wFOF - REST.t) ISM176>
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(IRA011'44G Ei sb3.000-423<tBJ(F.. $rfJ:{P�3
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DEVEJ.,OPER. 8i0f.J+r�t�"1' .I;W3 s
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AR T IN PUBLIC.".. PLAC KS - AMR: 70J. -W, 0.255 00D �J►,ci�U
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wf_1f3-i?.MALC0I♦,i; MlJC`-`10NANT) PLAN CISECIC;,
n,749. f.
UDIF 'S
LESS PRET, TL
TMAI, ?R.,01l6:tIT ~ERIN .d%UE .l'i'{,5W
$3,249.11
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•
RECEIPT
DATE
8Y\_,7._DATE
FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
I INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
01 -All
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
-L
Exhaust Fans
O.K. to Wrap
-S-10-00
F.A.U.
Framing
Compressor
Insulation
@p !tC
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath-
Final`8( F�v_l �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
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
_z_
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final _ )�'QD
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)
COMMENTS:
S
Certificate, of Insulation
Your HoB,e iter been i�iated with Oettain'Teed � Imsulation pn+�4 which s� desired .
&r 6dWs safeW s=&w& and imrimw% anow re*wvmml&
bWWM Y- to be.fteiw, , - , � r
with 'fire- tiara� rhc� mkc *0 wilt 16* loge 9�prj�m� ' T 1�&
0 taks
"
se4tle aver
time as niiw ot6ff,ina lation materi9:
This'afto derldfim that CartainTeed IPApd GIam-Inmfiafiim has`bwn PtiaEete lamaw installed in this hum
to provi&the-fidlowing the=0 paWjWjao&.
Job NWne: Snrim Trick' 25953... Plimth. 4 Phew: 3
7�
W lqo.-.' 63 Job Addms; 4444S Calle MuftMgrbi� M Quints, CA
C"rmg Area: W�38 Unfimd Garage-
InbWair Walla:.
OvPxh�ng9.
RzkriorWalli: R-13 Un&66d
was Uld"AA- —Abovi'
PXro
(2 tayervi c -R1,11wr.
Aw-
WmL Cm 917M
Conchita Ortiz, Secretary) treasurer. —or— R. Scott Jenidas, President—or
d a Mero4 DkecWr of Operafibim Officer
P. mcans, remsm= to hut (low. The higher the R- value, the smaber the insulating power.
Ask yaw builder for the fitat sheet an R- values. Kwp this acr.tificm with your go=
v� papers. if yon ever sell this home, this us oficam p
should be used an to ft buyer.
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