9910-199 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that 1 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
697117t . 1013:1%'f9
ate I%A`mI`O .Signature of Contracto
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury. that I am exempt from the Contractor's
License Law for the following reason:
( .) l,• 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:
() 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.
N) 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:
Cartier 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 3 00 of the Labor
Code, I shall fort with comply with those'6r vision
ate: �� �� Applicant'Iy�'�'"�" I✓�•�'+✓
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 insp cti n purposes.,
Sig ature (Owner/Agent');a_6 - Date�'�-
PERMIT #
BUILDING PERMIT r.. ,.
,
DATE �A -VALUATION 1 "�q 1�; =i.tD .1_10T- ( TRACTJOB
SITE
ADDRESS -980..E�.�.e�.F,SANTl�,l.i�MUTAR
APN
OWNER
CONTRACTOR`/ DESIGNER/ ENGINEER ,
�f OT,a7X A'AY'4` h li'i tb!'Y{{ { Y e t. +:�f't '' �' Y 't
in•f. . 1tl �jt � i-i,�t,r_I to 1, i..� f. ��.14{.i ^i •D4.v�✓�..r .�tiil..
f�FJ1:{ A �,9� A.�tit('� t ITf Q /� �, E'i°�y'• 7' 7t^'
i,rj,,.{a a.1,:"�i5� l 1'L.t'a 1-.i �' 1/��u�B'Kf\6� �}iY'.J�.._a l.i�a l-.
_900 ,ttiV:L-ATLE 0)F ' U: :L I"AT S
PALM DEM -T CA SQ211
RALoltv@.DDSER.T CA. 92211-
r�r�tt� MAI 520-1
USE OF PERMIT
SD. LOT 1 PLAN .ICR..MIT i O&S' NT" 1Kli tfM Hf.OM''. WAU. OR
Y{3t�f:.7 °�bl3ts?Itr 'IE t� FEK ON 1` a1f.:YL'I`IPLU i&SUA1 CE OF* SANTE PLAN,
TYPE.
,; RA{:•"1' CONSTRIJCTTON 4171Y6.00 a.F
PORCMI A1110 38.00 SItl
496.00 3F
. A a YB'�I Ai"d fl6.fl/rlt.i W6aY Bii.E� il..'1Ab'i.,Y M'Kl.ii�An^.'a.�y'G
104,75 70.90
C0I%J13TRtK,'T10N Fai 101A00-418-000 $657.00
PtiANt CHECK FEE WI...f}W-474.318 $740.19
iisl {."E{Af�'1Cr"!�.• 11.01 -owl -414, $47.00
KUNMING FEE 10 d -OOCE 419-000 isi 58.7
Tf`_R0NrQ., M{YT3ON CBE - RESTO 10i -OM -2-41410 $10.0
GXLAMNO HT I01 -0004234M 520.00
ART IN K.T61AC PLAi:.1<:8 - RESM 701-030-25-S-000
E*11VELOF°.ER IMPACT I ilk
i-
SI, fB-'1'l3'1Ai: +��'.`.Nti"FRUC'D` 0K AND PLAN 0-HY6.'l4.
LESS PRF -PAID FEES
0
)x�
RECEIPT
DATE
By ` '
DATE FINALED
INSPECTOR
M
INSPECTION! RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
'11Return
Air
Steel
AS,,
Combustion Air
Roof Deck
S. jq_eQ
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
-a L,
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wali Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final � I (�flp
BLOCKWALL APPROVALS
Final
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final:
Gas Piping
PLUMBING
APPROVALS
Gas Test
Electric Final
Waste Lines
k} j-•Lt9d00
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
CD
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test �- g • c9p
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final Q
Utility Notice (Perm) Z71
116WO
Certfficate of Platin
Ymw Rom •bas beat iim"ed with Q=inTmd F:re s Iasitlatioa pioducts, which ate designd
tur. to&q% satiety: 8=&X&MWtna�airaw's e�nerBy requi�aeats
Fi�$lass is iubrg�ticandt,�tefote.permaneatiy,noioicambust<ble; so itches nottia�rit�lo
witL fue- ch ic�Is then w l l�tcely:ioa� their �'ed mpm over time_ It has notbeen`trested
wiih chemuals tiiffi caa iaanode wrong Qr; metal diel �will nut abaimb moister nai swill it
setts avec time asmay cubist ioaoiabio�i.mate<tats - .. .
This also aertifica s,*= CertiiiaMW Fiber Glass Insnlation ims been ps ftdonaW roes Uad in this home
Uo provide the foitowing MaMd Pe�armance
Job Nerve: &Mil a. Tract: ISM Plan k: 1 Phaae:, 3
Ltit Na:' Y Joh Adder:<"98 ;Cshe Vz� 8wtm La QRklte, CA
Cabig Area. R-38U�aced ; Ga
r�g CeaIII
B
_ _ �1!itti"B�ieingllhav� : .
7aterior Wails:
Oftrhm prior Walls;. R-13 Unfaeed
Paictf RfaDB• Wd g'"aie
&the' ' iracioi:. OJlr sul own Co,. I
aofls: , a� � s»ai ts�sia�o rroe�i�o9
eondkira,Or4. SWreta q T'rm*ju r -nor-- �,R. Sciotl Apkins,. Ptresidentr-or
Lou Mettvlay DireC.tor ofDperardioin Officer
R- mks wAidance to heat flow. The hider the R- values, the greater the insula�g power.
Ask yanr budder for The fedi sheet on R. values, Keep this outifigte .with your other
valued p9p Ifyou Vw sell this home, this oeltificate should' be passed on to the buyer.