0006-188 (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
4188 B W31112(
�DateR'�Y�� "" Signature of Contractors ' I ' ���l ✓
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).
( ) 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
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 GOLDEN RAGLE 1N£, Policy No. biWC-544069-02
(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
ode, I shall forthwith comply with,thoseprovisions,
Date: + � �I�nApplicant
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. f
Signature (Owner/Agent) ' -mow Date -
f'. BUILDING PERMIT PERMIT#
DATE VALUATION LOT ()00&168 TRACT
$1,50,449.70 19 20158
JOB SITE
APN
ADDRESS 63 CAUT Er NORI`CI..
769-022-03€1
OWNER
CONTRACTOR / DESIGNER / EN (NEER
CEITIURY CROW M COMM,i HIES
CEA3 URY CRO LL, Ct?WdUI l3ER
1335 1,30, M" r EEM, ME #200
1535 30, T" 5TULT,1M, 4200
SCAN BnKARDINO CA 92408
SAN BERNAT DWO, CA. 92405
(909)381.6007 CAI.t 2120
USE OF PERMIT
MOLE kAIVMY 9WM U14G,
SVD- LOT 19 PLAIN IAP -PERMIT DOES NOT INCLUDE RWCY. WALLS OR
POOL, 751% PLAN CHECK ME R,EDUCTIO14 VOR. ISSUAMCE OF SAME
PLA14 TYPE
CUSTOM C0143TRUCTION 1,503,00 SP
0ARAGMARPO12T (Shj 4,996.00
cis
Eg,C`.11 U Cd?sr.or. CO URUC 7C)n
^350,a��'i6l
CONSTRUCTION FEE 101-000-41,8.000 $819.00
PLAN CHECK PTE 101 -OW -439-:418 $164.82
f1�7
MECIlAN1CALFEZ 101-000-421.000 $53.50
111n'i
9I.XC:TRICAL FEE 101-000-420-000 $105,31
PLUMBINOIEEE 101~000.418.000 $tIV, M
STRONG MOTION PRE - RESID 101-000-241-000 $15.04
t`tl 1
ti_J
ORADINO 17,9 ` 101.000.425.000 $20.00
EILVELOPER IMPACT FEE $1,4177 00
SUB 'I A% 0099D2II'MON ,AND 75L" CEELK
$3,222.42
LE38 PRE—PAID FEM
$0.00
T917 t,11XMW '>t"_MS DUE NOW
I
0,222,42
RECEIPT
DATE
BY/ f ).
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
__
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
/Z -D'O
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
Drywall - Int. Lath
Final
Final
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
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:aa
,
Final��
� "
A9 -1l /�
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)
- "
:MAY-25-2001 16:02 WESTERN INSULATION 909 686 8786 P.20%27
WESTED" INSULATION' INCs
421 L LnthaM Street, RivrMift CaMMia 92301
y, Tel. (909) 686-8760 Fax (909) 686-FM
INSI!A i° ON CERTIFICATE
THIS IS TO CERTIFY THAT INSULATION HAS BEEN INSTALLED IN CONFORMANCE WITH
THE CURRENT ENERGY REGULATION, CALIFORNIA ADMINISTRATIVE CODE, TITLE 24,
STATE OF CALIFORNIA, IN THE.SVILDING LOCATED AT%
TRACT / PHASE: D.UNA FAIRWAYS — 20168 PHASE 2
LOT # 1'9
SITE ADDRESS 78-083 CALLE:NORTEllil QUINTA;�CA
EXTERIOR WALLSn
MANUFACTURER: JOHNS MANVILLE ' THICKNESS: 3 5/8 " R-VALUE: R-13
QEILI BATTS BLOW - 1
MANUFACTURER: GREENSTONE THICKNESS: 8.1" R- VALUE: R-30
r BATES::> SLOW
MANUFACTURER: JOHNS MANVILLE THICKNESS: 11' R- VALUE: R-30
GENERAL CONTRACTOR: CENTURY HOMES
BY:
TITLE:
DATE:
INAULATION CONTRACTOR: WESTERN INSULATION, INC.
LICENSE NUMBER: 481275
BY;
TITLE: PR D CTION ANAGER
DATE �y
F
t
CENTURY BIOMES
Century Crowell Communities
Tract Name
Tract #
Lot
Phase
J
�� f2 on the above referenced Int
will be done by outside subcontractors.
Date
s Age
1535 Soutli "D" Street, Suite 200 • San Bernardino, CA 92408
(909) 381-6007 • FAX (909) 38 1-004 1