9910-389 (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
697117
Dke' Signature of Contractor95 4W rir
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.
NI have and will maintain workers' compensation insurance, as required by
Son 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.
71'ATE3 FUND 467-9 .y -tai' 0
(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- thoseproviions.
Date: Applican ��� �"�"'�� ^^-
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.
Si ature (Owner/Agent)' ?T4 4 Date Alm
BUILDING PERMIT" PERMIT#
!
DATE f t VALUATION S4Q4,,k%9 I0 LOT (1} TRACT 2595'A
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t'JOB
SITE
ADDRE S 44 -INS CA.f}uiU, SANTA .B(�4:E�I�itO�E�I.
APN
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OWNERt
CONTRACTOR / DESIGNERENGINEER '
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77-%v" AVs .?v—L.'V O1: 1714E 3TATFS
i 7-900 ,VENUE QPTHE HE S'.C'AIES
PALM DE-SWf CA 92211
PALM D1-S.19XII CA 92211
fiY004,�.2t5u CBL# 201
USE OF PERMIT
SINGLE F.ti.INULTY laWEL1AINO
Nl�t� LOT 6.1, PLAN 5i7_ P110A.► d' 19t71314CYT ONEM, LW. BLOCK 'tNA , iiit.
Y'001.,75%r hMVC"Pl.0N FET. OW n?Ui...' IMS, ISSUMIM OF � ANA, PLAN
TYPE.
TRACT i CiNS RUIC"i ION 7,480,00 SIF
i1ORCIVVI TIO 19.0 W
GARAOFYC'A►RYORT 6% .00 I F
' USEMtTWl"COST ANC"_ NMdCCION
14315S9.00
E MA7FEC SJyLWlRY
C)ONSTRUC r ION FEM 1.411-1')6ft)-4141-000 Sin. U4
PLANt°.+?f F971 I0}_WO-439-24J8 $167.99
MW714.AMCAL PU 11�t
$9-000-41`91-0�0((y1
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ART I:.N PIRILIC.1'LiV.!,R4 - ItESIC 7111 -WO -2 -5.5 --WO StM.46
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Skill -T irk. ?, CXYN8T '1X7r10N AND PLAIN CHECX
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LESS PRE-ViNID FEES
14W.00
'O.O'Y'AL i".t+;4a:MIT if'1+"1" S 00:C NOW
4e I
RECEIPT
DATE
BN./ V
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings 1
Slab Grade
_ �C
, - o�
Ducts
Return Air
Steel i
Combustion Air
Roof Deck I
2 - 15 -c
Exhaust Fans
O.K to Wrap !
3— 10 - 0.0
F.A.U.
Framing
- 11, - 015
Compressor
Insulation
3 . a -do
Vents
Fireplace P.L. 1
Grills
Fireplace T.O. '
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
3 • - a;0
Drywall - Int. Lath I
3 • S2
1 �
Final
BLOCKWALL APPROVALS
Final
POOLS - SPAS
steel
Set Backs !
Electric Bond
Footings f
Main Drain
Bond Beam
Approval to Cover
t
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines j
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans I
O.K for Finish Plaster
Sewer Lateral 1
'Z -
Pool Cover
Sewer Connection
Encapsulation
Gas Piping i
(t -t3 • 9,0
Gas Test )
Appliances
Final
. i
i
Final
Utility Notice (Gas) m ��
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures t
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors 1
Temp. Use of Power
i
I
Final
Utility Notice (Perm)
COMMENTS:
'
f. a ..._—.. -
Certificate of Insuiatioo
yore Nnmt Bas been imsnlatad with, C m'Teed "I ss me Insulatiom pvobcts. which are.designed
Cor WWS mffc9 standar8s sad tamor.W's enragy roquirom ,
Fiberg]ass is &"Wdc and t�eime pity noaonmh le,'so it doss aoi bm to.be treated
w� fidretardant micels that w�1I Llaelg-lase ytBear e�reness over ti�te• h iias•n,ot been meted
with c�emiw]s t>tai corrode vesting or meteL^ wt7I'hot sasbr6.meistare ear will it
setOle aver time as mase ather insulation maftaals
'ibis also certifies that Certain?eea Fir Cteis.inadation has bma pia immw installed in this hams
to psuvida the 5ollowing thea�aL p da®anoe
Job lNamm Sonnsa Vact: 29$3 Plea S )Phase: 3
Lot No.: 61 Job Address: I4 M CsileVista Barbra, La Ominta ICA
Ceiling Areae R-39 Unfaoed
Garage Ceiling: _
R! Invgtg
- Above
Interror Walls• `-
• Over a Bxlerior Waller R-13. Un aced , .
Pany Waft.. �iRh Llviiag Abdo
aPcilhems:
�ttrrrcYor.. atllhSil lie t Ca,. Inc
00 v[t caw. Ames s err:6o711 i o9
Conch a �, Secret�ry/Treaseirer or— R Scott Jens; President. oF_
Lou. ModA% D&e 1,6,r o f Operegans Qfflcerr
R- means resistance to heat flow The higher the R value, the greater the insulating power.
Ask your builder fgr.lhe.Fait .sheet on R- values. Keep this `cadficM with your other
valued papers. fry" 'ever to n this horse. this certificate should 8e passed en to the buyer.
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