9910-200 (SFD)LICENSED CONTRACTOR DECLARATION
lihereby 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
07113
DNe- ➢ - Signature of Contractor%r4(g6 ..Z Z /2 i- �r ---
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).
O 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;
( ) .1 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.
iT A'I E FUND 467495 -01V A
(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, l shall forthwith comply with those pr visloj�s.
te: 100,:V5Applicantzi-xv
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 perfo.rmed.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
ignature (Owner/Agent)����.. s�� Date PIM -
- PERMIT#
BUILDING PERMIT
5) p
1
DATE VALUATION . .-!rVQt+� qd LOT ,N TRACT
JOB SITEµ A. ,
ADDRESS 44-950 C �i tl�r'>�Ia $i'eS`4*rA . 0.HARA .
APN 0
OWNER
CONTRACTOR / DESIGNER / ENGINEER
C}I,.Iota''Iti`1'AND W(I,1:leElM.`5 Yr`.
0 TIS$iA,,T./�aly1�:'T�t�fl:t_ JAJ1i A;'a0C.L°J��:
77-M) �:�rEME O TH STATES
77..E ,��v�.�t�E cW T14 , Rl'i ES
PAIM DESERT CA 9: 211
RALM DESERT CA 91,21 t
USE OF PERMIT
SINGLE PAIN'i.TLY DWELLING
%D, LOT 21 PLAN 4A_ P01MY WALL kalt
fy1'10L-7 /'4 RW'UC:'C ON Flaf.ON MUL i..i7PLE 1SSUFtWWCE OF SAME PLAN
WK.
MWA1t0 70.0 Sr
GA1tAG&CARPOR117 679.00 ,SF
. irt�•lf , S�RJ �3:�.4d `L F` 6.t �4r• iN .".Y.M M'0'/L`4
j 0111311tUC'1'JON r- M 101-04041"00
FLAN CMM' FW"s JIM -01-4-19-31.8 - g. �
Cir$EC;`13h:NIt^.r' L ME 101-M4212 000
,ULk'A','TIk1CAL 1 -ME :$135.16
PLUMBINO k,R?Ci i4g}�F3$1f$-4X�-33r'lE} S.4- °4309
STIRONOlb9' T1.0'KFRE itT:°'SID 441-,M-241=000'
c,3IdAi71t3Ci 1'3< 101 -0th -423- ti!)'
ART IN S otJ%tc !°1 m,Es - RFSa: 701 -00G-7554M, 169:1m
LESS PU.NAIL Tom.ES
w$)°(i'!)
TOTAL VE'HKrW'VE%8 DUE NOW
11,249. 11
��'y
RECEIPT
DATE
BY°--�
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
417%'Return
Air
Steel.
V
Combustion Air
Roof Deck
; . (.!5 -Exhaust
Fans
O.K to Wrap3-30-0—
F.A.U.
Framing
Compressor
Insulation
_
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
SdeS-6®
Drywall - Int. Lath
Final
Final
���H_ Co
POOLS - SPAS
BLOCKWALL
APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam .
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVAL$
Gas Test
Electric Final
Waste Lines
I a,p .- c3m
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Z - Q
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Testg
�� .cap CQ —
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
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)
Certificate of Insulation
Your Homs has been insulated with CcMinTeod Fib®glass losulatiou which are: des�gaed
%r today's satiety 5WRderds and tomarrevVs energy iegnicemeints.
Fuss is iaorpnic.and theiefine"Peamaae * nonowMbwgibleti w it does not have to be treated
with fim4e6d= chem cab that wdl ti d* lose their of cmveuM uver time; It bas nal been treatod
with chemicals tient can comode t UM9 or metal. Rdmigtm will notabsmb mnismre nor WIM it
mWe over tune as may atter hum alion mwerial&
This also certifies tbat Cea fainTeed .Fiber Glass InsnlW= has been PwAmsormliy inavalled in this home .
W paovide the fbiiowing lhmmal pew..
-Job Name: Sonrfea TCW:L- 25M pka d gear 3 '
Lot Nn: 2 dab Addrew 44-"0 Cale Yula Badwa, I.a QnirRa, CA
CeUhw Asea- R-38 Unfaoed Garage OdMr-
With Living Above
Interior Watts:
6Nhurfor Wetter R-13 iJnfa�d
Pam Walta. Whh thing Above
(Z laycas) CaTmg Badit :
SubcontraCtor.. OJlnsuladon Co., Inc. -
bon s vbpf% Alza. +4 siren (C6) MaAD70 Umwe a9
Canchitu Ortr'z, SecrelmyArreawer ter— A Scott Jenkins, president-or—
Lou Merola, Director of Opera&ns officer
R- means red=noe to brat flaw. The higher the R. veils:, the greater the mdaling pouvRr.
Ask Your builder for ttte W sheet on R- vdum Keg this oeatificale with your other
valued Papors. rf you ever sell this houm this oetificale should. be passed an to the buyer.