9910-190 (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
697.117- B . 10/31/20t
6to �r j� Signature of 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).
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 perjuryone of the following declarations -
I(, ) 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.
STATE FUND 4f,7-n5'-t1000I20
(This section need not be completed if the permit valuation is for $100.00 or less).
O .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
ode; I shall forthwith comply witthose rov Bions , --
D te: Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnity
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes. .
S)ture (Owner/Agent)'%!&, ...,-/�yE-L�2�✓ Date 2Y le/'rl:l
PERMIT #
BUILDING PERMIT'
9903490
DATE VALUATION �''R11,�_ LOT, TRACTgti9y'
V10 1q,
ITE
ADDRESS �i�JOBS�l.� K�;�A.. R a�P.d N �'d�l R8.f�.��L1�.0 L�
PN
OWNER
CONTRACTOR / DESIGNER PENGINEER
OL1'3'1-1R►VI'T AND �o11LL1AAAS A.ti a f'(`.,, :rNC_
01..11'i1A,wr AND W11.1,1A%4S A&SSC„ :N C.
7i• t10 AV 13UE (3.E~ "i l]s '/A'i:r a
77-900.AVENUE OF THE ;a1 KFES
PALIM bESTXr . E:;A. 922 1.1
PALM 17BE RT :. CA 92211.
(160)345-2626 0131:4 5203
USE OF PERMIT
SINGLE FANUL IYWELL1NG
SFD- LLT 62,K AN SWPERMIT TDt" RS INOT [KCLUDE, ER .00K WALL 0.
1Yi)OL.7.-',/a Rk2JV(:rf10.1w Fi7d ON NfULTTip1.E, ISSUANCE Or- SATWE PLAN
T"Yt E.
UACs CON TRT.K.170N Sr.
PORC,WP'A110 7tY.t21s SM
0ARAZ§BfCtA22f'+,:e$Z. t' 6'%, W S1;
°EST11,11Afri..D CWT. OF M1`3S'fl'aiUMION,
PT! R AUT FTL1•.r. iTft f1KY
C'0NY1'RUUr10N VIM 101:-ipfii)-4.1.8-0110 SS.11.00 '
P!, AN CNFCK FTf.F 101-t3itU 439-318 $9.117..99
MECHANICAL FlE 160.00
O,ECi`t2ICA.L FEE 161-._.0004,210•-009 $.1$Si �•2
3�1 Ui�ifN! r FRE 101 (3430 X9.1 11`'0 $160,00
I-°1"1?.ONO W. Y1'10- N R . RE -IS 1") 111:143(3 3-;x41-00 $14.86
GRADING F U., 1.01-000-42 00 $'20.00
_0E" Ot Eft. 54PA r FE $007.0
• c" ;:
ART IN PURL FC PLACES-13.EWC � N -000-255.000 $121.40
St 'i"rR7T'AI.., CONNIS 'RU TK)K AW-) ,FT A2q CHECK
4:t^
$3,410.67
LESS PRE -PAR) 14 1 S
$0,00
TOTAL Qp6`10'41'iF FEES Al Ull'i"l`!"ow,
&k,410.6
1
RECEIPT
DATE
BY U
DATE FINALED .
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings I
�, -
Ducts
Slab Grade
x
Return Air
Steel
Combustion Air
Roof Deck 1
ti -L-3 —m® r/i
Exhaust Fans
O.K. to Wrap I
F.A.U.
Framing i
<2l— Y
Compressor
Insulation
Vents
Fireplace P.L. I
Grills
Fireplace T.O. i
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall i
Exterior Lath 1
-3-�
Drywall - Int. Lath
j
i
Final
Final 1
POOLS - SPAS
BLOCKWALL
APPROVALS
steel
Set Backs ?
Electric Bond
Footings I
Main Drain
Bond Beam 1
Approval to Cover
I
Equipment Location
i
Underground Electric
I
I
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines i
_16— 91F 16
Heater Final
Water Piping 1
Plumbing Final
Plumbing Top Out i
Equipment Enclosure
Shower Pans I
O.K. for Finish Plaster
Sewer Lateral 11
2,— if-
Pool Cover
Sewer Connection l
Encapsulation
Gas Piping
Gas Test
04
Appliances
f
Final
I
COMMENTS:
}
Final 1
Utility Notice (Gas)} 124,
ELECTRICAL APPROVALS
Temp. Power Pole I
Underground Conduit
Rough Wiring I
Low Voltage Wiring
Fixtures
Main Service I
Sub Panels
Exterior Receptacles
G.F.I. I
Smoke Detectors i
Temp. Use of Power
t
f
Final
Utility Notice (Perm) o t
C eft Bate of Insulation
Your Home bas been insulated v&b CarWnTeed° i .
Ls4ullatiun whim are des;gaed
for today"s safdy stand" and tomortoWi ems' ^tOtjlIIrEmentB,
FibCrglaaa LsInFW,3 C a" llle�.permRnrndy IIOIICQm�11St1b%y so it does not have -to be Utated
Ar1th SIi�I�tardaIIi
C�ICBIS that w171 lase thC�r "dYrii �� irheS ae�i bei treated .
with Chem;els tliai cau wnodc avian g uFr nzetat Fuss will' rint al" mDistam nor vM it
settle aveitanZe as mey other ia'sulamna toate<ials.
Tbm also oest&cs that CatmnTeed Fiber CAm Iusni-hon hes bsenpmfis+donalty, installed in this mm
to provide the follamng thew! pedunitance._
Job None: 3onrisa Teed: 25953 )Plait M 5 Please+; 3
Lot No.: 62 Job,Add:em 44-M,Calle. Vsefa Bw%m La Qui�fs. CA
Cealra Areas R=38 Unfaaed Gaeage.0
Wittr Li g'Above
II�eeior Wella• ;,
OveflusgNiorWaila: R-MUnfaoed
Party WnftWiffi Livigg Above
°. {2 bayers) Cewmg RsPoeis:
.� Atm �a 91'I'aE-(6�6}8f2.6D70 IJosat1066709
Conchita Orft SecreAWyl4! reas;urer-nor— :R Scott Jeiikins, President—or--
Lou Merrok Dir"tor of Operations Of jlcer
R- means. reAstnoc to heat- Raw, Tho higher. the. R-, vatu4 the greater. the imiulsting,: power.
Ask ym builder for. the face sheet on R values. Keep this artiflaate with your other
valued peepers. Ifyou ever sell this home; this certificate - should be passed on to the buyer.
A