9910-203 (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
Nte 11 16 !21 Signature of Contractor "`ZZ,,
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).
( ) 1, 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
pelformance 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 wlth,those prov' Ions,
Die: `)/ Applicant
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.
SignXure (Owner/Agent) � %'�.�- r«--tr .•! ; ;^y.� Date f �
I
BUILDING PERMIT PERMIT# 33_103
DATE t ( J/' y• VALUATION LOT S TRACT
JOB SITE N APN
ADDRESS
OWNER
i rr�o+:� �;,�r` •+�n��t "�nX► �aera es+firg
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7
PAI'..�i%4� �(LvL+L�� y f
USE OF PERMIT
kR•i(i_A l;Wt l,' UN t
CONTRACTOR / DESIGNER / ENGINEER
Y��a.+.e,"'ii.i i�a iii i4.% ��vai.z. e;ii�oii ro���`�i.}"ti.• ��,+�_•
:i'kt. i..,t ..:. R't.;1;r .SA. lil:d441f1I L)t3�i f*tl+�l 11Vl:�..A.t'I.kI~�43..�>l,:ib i�frtyl"L yrtt.
IN V61 (. N NNIOL 11'1'1,1 1331LI P+ll.'.1^:4,* ' fAN .4. PLAN
I'YI•' "
Cfrld rl '►1FJt. A.ii1't..l 'I' 43S1 .00 S
Jt ERMi
('l1NS°I`RU(' 10N FLT
!014*041940)
S,776AK)
41E("[Ii'NICAL T TE
W) .121•.000
Serla.'ttt
Et.R".'I`IZic"AL FEE
!C#►.fit} $Zfs-U!}i1
�d ii4).�ii
F't,1S")1NQ PIEF
S169 'k
w,rRllNl7MIt.:;111DAt1�k� -M1 :';1i�
{F)1 {> tb-2, 1•t
It11i+Fr
GRADIIdGFUM
$20.90
LH::C, EIA"4+ "'ACT I' FEE
S t.90, Ilk
r;R I' tN 14AILR7 I4..r#Ch 3 - Eti :'III:: 701-40),.2M-',XX)
'I96 2W
RECEIPT I DATE
141331R4016.40
'� brit►?. `+'
'1'[.d Ft'+.4., 1'k.4 N11`f' if!' ,*,*t 01- 4'- "+it lW I $3_441.54k
DATE FINALED I INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs I
Underground Ducts
Forms & Footings ;
Ducts
Slab Grade 1
�, '
Return Air
Steel
A
Combustion Air
Roof Deck
3 v Z3 y
Exhaust Fans
O.K. to Wrap I
F.A.U.
Framing 1
t4• i (-
Compressor
Insulation
'- —
Vents
Fireplace P.L.
Grills
Fireplace T.O. 1
Fans & Controls
Party Wali Insulation
Condensate Lines
Party Wall Firewall';
Exterior Lath
Drywall - Int. Lath '
S - v? -CPO
1 �Gr __
Final �
--
BLOCKWALL APPROVALS
Final
POOLS - SPAS
steel
Set Backs !
Electric Bond
Footings
Main Drain
Bond Beam {
Approval to Cover
Equipment Location
Underground Electric
1
Underground Plbg. Test
'Final 1
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
(— Zp _00:
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral +
Z —
Pool Cover
Sewer Connection I
Encapsulation
Gas Piping
Gas Test ,
_
- • 47 �J�
Appliances }
Final
Final S�
Utility Notice (Gas) mYXI
ELECTRICAL APPROVALS
Temp. Power Pole 1
Underground Conduit
Rough Wiring i
Low Voltage Wiring
Fixtures I
Main Service I
Sub Panels i
Exterior Receptacles
G.F.I.
Smoke Detectors 1
Temp. Use of Power
1
z
Final 1
Utility Notice (Perm) (sn
COMMENTS:
-
'
Certificate of Insulation
Vow Home bas been insulated with CmUinToW fibcWam Insulation p;g" v&fi h an designed
hk today's saft standards andtatnmmWs energy mgmx mcnta.
Fmergiass is i�torgatuc aad tlieieforc nflnrom>sbble, &o,it does not have to lse tested
wtb fin} ch'emirals that wilt hlo y lose�their effecdveoew over ante. Ai has nut been ir�md
with chemmcaLs.t3bat man cbirode wm9ornm;UL Fmm9umnnr wits it
. - settle oval time as m$y :other msu>�on mateiieits. - .
M& also certifies that C tsinTeed Film Class inaolatina ties bet n i®aliy iastalied in this home
top avi ft foil-, ; noe.:,
Job lame: sohhm Tm.ct :?5953 Plan d: A.- Phase: 3
3 Job Address::44'� O Calle Vim Barbra; CA .
Ceffft Aires: R=38 Uofaccd Garage;Cefiiing: _
Inteiior Wells: �, llb for Wade: -13 Un&ced
Party Www: With. Iaving Above
(2 laic") ag'BAdlbE;rB:
Subconftelor OJImmkidon..Go.,-I=
s Am� Cm "AM 03ijM-a7o U.06M(M.
Sigaedmg
conchma OrtdZ, SecretorylFreasurer --or R Scott Jenowl President—or
Lou Mero!'a, D&edor ofOperations Offlc&
R= means nwstanve - to heat flaw. The higher the R- whip, the greater the insulating pmm.
Ask your 'buddlw for 11!a;, fact sheet on R values. Keep this oerti5icatewhit your other o
valmd papers. If you ever sell this home, this ceiti5cato should hepassu on to the buyer. ru
00