0002-459 (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
Proi,A�sionals Code, and my License is in full force and effect.
License # Lic. Class Exp.. Date y
r114�`fih IJ 3tlt�§�,-.QJt
D'664�X?'_1_7'1 Signature of Conte 0. �
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 & PrnfPs'innals Cnrfa)
( ) 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.
I have and will maintain workers' compensation insurance, as required by
Se�, tion 3700 of the Labor Code, for the performance of the work for which this
peimit is issued. My workers' compensation insurance carrier & policy no. are:
Cahier Policy No.
(,CAt�f`s..'.-1�;Lt;1"3;�. `"� `(' •11�6,�rUi
(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 t• -the workers' compensation provisions of Section 3700 of the Labor
Code, II haft) comply withJtaose pr vision
Dat � /Applicant C..�•�
Warning: Failure to secure Workers' Compensad�• h 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.
Signature (Owner/Agent)Dat a f
PERMIT PERMITt�fikt_4.iyDATE
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41 F_�LBUILDING
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ADDRESS
OWNER
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RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
S)
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
Underground Ducts
Ducts
Slab Grade S /,J =pa
Return Air
Steel
Combustion Air
Roof Deck 00
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing &z;,
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath �y
0
Final
Final l
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 APPROVALS
Gas Test
Electric Final
Waste Lines — pa
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
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)
NOV-21-2020 13:47 WESTERN INSULATION 909 686 8766 P.21i24 I
VMTERN INSULATIONIINCo.
4211 LaUmm ft=% Riverside, CaUbmia 92501
7,C (go9) BBS -8760 Fax (909) 686.8786
_ t
IN&ULATION CERTIPYClIT�
THIS IS TO CERTIFY THAT INSULATION HAS BEEN INSTALLED IN CONFORMANCE WITH I
THE CURRENT ENERGY REGULATION, CALIFORNIA ADMINISTRATIVE CODE, TITLE 24,
STATE OF CALIFORNIA, IN THE BUILDING LOCATED AT:
+ I
TRACT / PHASE: STARLIGHT DUNES - 23773.4 f
r
LOT # 17 }
SITE ADDRESS: 78-730 ORION WAY; BERMUDA DUNES, CA
--- -------------------------------------------------
MT0 1108 WALLS:
MANUFACTURER: ' JOHNS MANVILLE THICKNESS: 3 5/8 " R -VALUE: R-13 {
CEILINGS; BATTS BLOW i
i
MANUFACTURER' GREENSTONE-- THICKNESS: 10.3" R- VALUE: R-38
CEILI BATTS SLOW 1
MANUFACTURER: JOHNS MANVILLE THICKNESS: ' R- VALUE: R-38
GENERAL C NTRAC'TOR: CENTURY HOMES
BY:
TITLE
DATE:
INSULATI®N CONTRACTOR: WESTERN INSULATION, INC.
LICENSE NUMBER: 481278 '
BY:
TITLE: PRODUCTION M NAGER , f
t'
' DATE NOVEMBER 21, 2 -
1
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