9910-201 (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. 1051/201
X
D�e Signature of Con'tracto
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I -am exempt from the Contractor's
License Law for the following reason:
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. 70 , 44, 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 -.Sighatue.e 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
prfprmance of the work for which this permit. is issued.
lhave and will maintain workers' compensation insurance, asrequired '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 17=33
(This section need not be completed if the, permit valuation is for $100.00 or less).
I certify that inthe performance of the work for which this per'mit 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
Cod6' I shall forthwith comply with hose * v siw-
r5ate:Ilh,&, I n 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 conditionsand restrictions set et 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 18o 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
Aature (Owner/Agent),&_,/_,/ ate
PEPIMIT#
BUILDING PERMIT
DATE VALUATION S;0C'7-.%'JJW LOT TRACT 25953
JOB SITE APN
ADDRESS 44-921D CALLESANTA RARBARA
OWNER CONTRACTOR/DESIGNER/ENGINEER
0LTKLA,%r'.rNK,',',) W ILLIANISASM.- C. OL.IP1 IA',,,,rrA!%'DWILLM.M''ASSOC.
77-900 AVENUE OFT HE S' TA`' 71-900 AVEWU oram, srKpis
PALM, VESERI' CA 92211 PALM DESERI' CA. 921211
(-")345-2676 J CK 1u 5203
OF PERMIT
SH41GLE FAMILY DWFLUNG,
PCK)L. 750,6 RhIAX-110N VEH ON IWLT 1PLE ISSIJANCE; Of SAN16 YLAN
TRACTCONSTRUMOiNl 1,736AIN) SIP
PORC"Xrio S8.00 SF
GARAC-MCARPORT 496.00V
. a 04AT2.10 UM G MJ1 DN
Esvlw r 't AZZU
-0
W7SIOSIV
FERAL NTEly SUMMARY
CON&FRIK7CION FEE
V67S110
K, AN CHEXX FEFF
1014M-419-318
$140.19
NIECHMICAL ME
$47.00
EiL07rRICAL F&
10.1:-0*420-000
IW_W(", 191-000
(IRADINO FEE
ART YN PUBLIC PLACES - lqh=
701--Ml 5-5-000
$11.89
DEVELOPER IMPACT FHE
X. *TRU(.7 'N 11) 11 " K
-IJB-TCMA-1., C YNS MY AN. MAN C EC
LESS PRE -PAID IFEES 00
Xv 'NOW
To'TAL PERINSIT ME 3 DIM.
RECEIPT I DATE
DATE FINALED IINSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs I
Underground Ducts
Forms & Footings I
6
Ducts _
Slab Grade 1
'Lj
Return Air
Steel 1
Combustion Air
Roof Deck I
3 Z,I -00 7f
Exhaust Fans
O.K. to Wrap I
_3G . BO
F.A.U.
Framing 1
4f - ��
Compressor
.Insulation 1
Vents
Fireplace P.L. I
_
Grills
Fireplace T.O. 1
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall I
Exterior Lath 1
s- ' $ 00
Drywall - Int. Lath I
7
I
i
Final
Final 1 IT[ y.(� Com-
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs I
Electric Bond
Footings I
Main Drain
Bond Beam i
Approval to Cover
I
Equipment Location
I
Underground 'Electric
1
I I
Underground Pibg. Test
Final i
I I
Gas Piping
PLUMBING APPROVALS
1
Gas Test
Electric Final
Waste Lines i
r•— 20 dd
Heater Final
Water Piping i
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans ;` -
OX for Finish Plaster
Sewer Lateral j
2 • h
Pool Cover ,
'Sewer Connection
Encapsulation
Gas Piping ;
Gas Test
Appliances t
I
Final
COMMENTS:
1
I
Final _ L
Utility Notice (Gas) Qv -
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring i
Low Voltage Wiring
Fixtures 1
Main Service 1
Sub Panels i
Exterior Receptacles.
•G.F.I. I
Smoke Detectors 1
Temp. Use of Power
i
i
Final ) aD CQ
Utility Notice (Perm)
Cerfiricate"of In's'U'lation
Yana Name has been ambOd with CertainTeed FibiVm Insulation =Iucb are deftmd
fortoday's suety slndw ds and UnnarmA =cva ie
E•ibai is ivarganic and t>ze:pe�ane�iy rioaco�e, so •itdoes'nat have to be Rented
with that. will Iikrdy rose keit
over- It bas pat been tested
with cab thm can eanode wiring ar metal Feber�ams wilE:nflt ahsozb moastm9e nor wilt'it
areola iinmatats
This also certifies that CalznTeed R" Class insulation has;been
Pi'aS' installed in this tame
to=p�vide ttie folla�ii�g,thetmat pncc . -
Job`Neme: 5otuisa Traces 25M , Fba #t _ 1 Ph e: : 3
Lat Na►: 3 Job Adder: 44-930 Calle Mora Basbm La Quin a CA '
Ce" Area: R-39 Untaoed
With Lblu AhGve.
'Luterlor,WaD�
OwrhingL
Elliriur VVetts- R-23` iimbced
Pmts Tfiatla: WiW �svlgg Above
CeaftigBafters..
of * ca.; ram
ate' n� '�ioz . � (ras) etr�'rB :IJomre #i6�70s
Signed
Coactiita SeCretarylTreaftrer --or— R Scott oeoki- S, ~Ifenf dr—
Lou er6k Director of Operations Offlcer
R- means te3idb= to haat gaw The higW the R value, the greater .the .msvlaling power.
Asir your builder "for the Ibd Shed an R- vahm Keep .this oeatific�e wide your other
vatted papers: If you ever sell this borne; this aeitiHrate should be passed an to the buyer.
N
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