9910-183 (SFD)LICENSED CONTRACTOR DECLARATION
nhereby 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
o i711 W;31/20
iV 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).
( ) 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
performance of the work for which this permit is issued.
(.'r 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„,,,C
Dte: Applicant ,a r"
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.
r
Signature (Owner/Agent) �'�Z� �" �-? �.. �' Date `
BUILDING PERMIT PERMI "11104"
i t � )){/r
DATE J}•, fG�� VALUATION,ay��d� gyt r, LOT(
JOB SITE Ar PPP TRACT
ADDRESSwi-�d,d-:Y l :.nii.1.:1'' ,"v �.�'ti I.,1'k,,1.��►i1..��R. APN
OWNER
77-9OC AVENUE O "114E: MATES
PALM Qe',,ShR 1' tj'A 42211
USE OF PERMIT
'I'NOL E PAN,111 t' 1.)WEILYN '
CONTRACTOR / DESIGNER / ENGINEER
i)j iIi11.AN- A.WIL1,; 1%IS iN.SS01,1NC
77- 00 AVENUE O `1'1.1E. STA'M
P..X1...M 'DE*S1aP1'ICA 0221 i
l7(o)34%-76m CBIJI 5703
0- i.i:,T 66, i1.AN 3A. pw i1T 1:i6f,S, WCi`i
Pit 4,41.,
PERMIT FEE, SANNIARV
e"t::)S�'3'E'E{!JC"1'E4)1V t�;k?,
1.!Di-f)Cdtf_.33�C•t�i(.f
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14I.AN /'" 1i (`K FN
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jiti9l_ g7
tti :r'1ix4lti1L�i1L. E LTi
if3l th`iS} < "� a 11tlfi
S60 tar)
E:11EC-TR.R'Ai, FEIP,
WlA".42Cr-000
P11U1K?+t9EN0 FEE.''
1471-iX0,410.0(X)
S'1 R(< !'40 W)'E'Vs N H+' - >NtF773If!)
I0I -W, ,-7A 140)
rd $4K
GR L)MG 111.
i0110M. '211(m
$2%W
L*V€i1.k)PFk 3EME", i"S' HT,
I, i/.i ►
AE2'E' ><N N4jklL.it" NE. i('E;5 - 4tF'Yll; ;s)1 1)43() t 15d)(X
fit'%1.40
K1fft-ITYf"A1, C`'t• NSrRJ 1t�."}' (VANT) P1-AN C4'R`K 46't
RECEIPT I DATE
T(>'ti Al, I"Ir.RiV IT Y 4±;EN 1"bUP NOW I S1914.4j
DATE FINALED I INSPECTOR
1p
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
cp
Ducts
Slab Grade
o o '
Return Air
Steel
Combustion Air
Roof Deck
3 .—Q� `y
Exhaust Fans
O.K. to Wrap
y _ 1 t —(q0
F.A.U.
Framing
g _ z _ rs�`
Compressor
Insulation
--Ob-
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
y— S,_60 t¢
Drywall - Int. Lath
Final `` TS oo
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
/Z
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewe Connection
Encapsulation
Gas Piping
Gas Test
-L 9 sQj
Appliances
Final
Final
Utility Notice (Gas) Ij
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) 7. S .
COMMENTS:
N7
s
Certificate of Insulat*
Your Home has beanins-lawdd{with. Cie WnTeed nI =wws IwvlM= Fo&C% which are defined
fW Wd �r. = �7 Sw"'k& and iOnimm4 =wV M*W mmis.
1.1erSJacs is inorganic and dierefOre pmnna tig ii0rit400mbusL q, so, it knee hist have to be bested
with fin-=UOdaw;c6emmcb* als that will lib* low their ef5e�v16KSaNer`time It -h u-nat been treatod
with.'cheumcals that ran aoimde wiring ar metnL: Feiglass Neill not absorb ni� nor will it
salla ever time as may al&r i>6sul on.
This also mrfiffit that CaioiaTead F her Glass limon h� been professiunaUy insllQd in this.ho
. 1� 1>�+ide�e`fuIIoaviag lhem►�lpetiis�aacie::
Job Name: uriea Tract: .25953 ipllAn #: S. Phase- 3
Lot No.: 64 Job Adder: 4a935-Caile Vista. Berra. La QgW*&, CA
Ceffing A>s: R-38 Uuf and
With Xing Ahove
InteriorR►eLL9: .
g� l awna r Walls: JK -&j Unfamd
WioW Llwhe Above - .
Party Waltt:
`` laymf
Comma. (fft SecreMUIDTamrer —or R Scott Jen nts, Pretaident--arr--
Lou Merolas Director of Opmardons O, jlcer
R- mean" resistanoc to heat flow. The higher the R- valae, the greater tho insvlatiug power.
Adc your builder for the far ep sheon R• values . Keep ibis oratifiaale with your other
valued papers. If you O+er sell this home; this oerbfiaate should be gaped an to the buyer.
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