0204-117 (AR)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
734094 .AB Inc�f � 3/31103
Date' ' Signature of Contractor lll_�<
OWNER-BUILDER DECLARATION
1 hereby affirm under penalty of perjury that.) 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 'theiproject (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:
( ) Lhave 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;Jssued. My workers' compensation insurance carrier & policy no. are:.
Carrier ZURICH Policy No. WCU22096-43
(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 shallforthwith comply withthose prq• visio s.
Date: 5102 Applicant--
'�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, indemn'
& hold harmless the City of La Quinta, its officers, agents and employee
2. Any permit issued as a result of this application becomes null and void i
work is not commenced within 180 days from date of issuance of •su
permit, or cessation of work for 180 days will subject permit to cancellatio .
I certify that I have read this application and state that the above information i
correct. I agree to comply with all City, and State laws relating to the buildin
construction, and hereby,authorize representatives of this'City to enter upon
the above-mentioned propertyfor inspection 166 poses.
Signature Date-
BUILDING"PERMIT PERMIT#
DATE VALUATION S Jo LOT , TRACT 28960
JOB SITEAPN
ADDRESS . .JT _P A. Tj 13AY-
I
t
OWNER b
CONTRACTOR / DESIGNER / EN (NEER
2280'4'Y'ARDLOW MCM,,19iiC 711.50
2i$0 WARDLfC)W .CMOZ, Wi'Z'e 150
CA P1`>'.20
COMMk`�4 41;720
(909r1279-4000 CBL# 57,61
USE OF PERMIT
T�MDINIIAL ADDMOX
S.E_M1N1-SU11'N, VnlLit UNDER CONSRUC TION
CUSTOM CONSTRUCTION 23200 8F
CONT T O.i,' 4rOitlfw'7.YC.F4J4.�A O
��))gg,ppgqyy��qg�^pp ((;;��^y� 2yp�y y��p'� �y�@ly�lAltVidAdi]r.V
➢:,Lr.S�,A.Y, IF dal Ll1V-fd'YJJ.9'A.GAd(.Z -
PLAN CHECK FEE 101.000-439-31 R 53:1,9
CIONSTRIJU'ION A`T 10.1-000-415-006 $45,0
1.Ft: k RICnfa sT; �11;a:�;1`00-42Caa�?i O $148
PLUMBINOFER 0. ttO
STRO1vC4 MOTION FEE- REBID 1014100-241.000
ART TR PUBLIC PLACES -1'+EM 270 -MM -44S-000
USS PRE-1AMIMN9
w
T(YXA .P1 t1M FnS MR, NOW
QUIOA,
Cta1yor-LA ; : }
FtP1ANCEDEPT� ,
..
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
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wail Insulation
Condensate Lines
Party Wail Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final _a
BLOCKWALL APPROVALS
steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. 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
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)
COMMENTS:
OL 17
11/15/2015 02:26 FA.1 . e002
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' IN LAITI®N CERTIFICATE ,
r This is to certify that insulation has been installed in conformance with the currerit'energy
regulation, Califomia Administrative -Code, Titb3 24, State of California, in the bullding located at:
.. J r.
:a �7`80.337 Spanish Say; Lot 39, La tuinta, California- ¢
F CEILINGS: { ;
TYPE: BILOW • MANUFACTURER.- Certainteed Thickness: R-33
WALLS:
s TYPE: BATTS MANUFACTURER: Certainteed Thickness: R-13
GENERAL CONTRACTOR: CENTEX HO -S LICENSE #
BY. TITLE,
PARAGON SCHMID BUILDINGPF20DUCTS, A MASCO• COIVIPANY LICENSE # 632072 '
TITLE: ADMINISTRATIVE ASSISTANT DATE: 1/10/2003
• f.•.'it:•/I:�.'fi...'/+%/.i.a•:o.ii/.;:;IJ:I%//J+15y/.:-ir:'rl;sii_.;=.�+.vrr::rvr.r:r:.•.:»er.r�nrivnnr+iiarr>ti+•r irr.�..*::..:r.+r/.�..•/v,:i/:•.%join.•:n:i.i.i:�'i!nvic.avirr..: ri.s:..•.•._� .
LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
1•— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
N W Prof essionals-Code, and my License is in full force and effect.
Lic. Class Exp. Date
� License #
W r 734094 A B HIC 3/31; 03
oZ r- Date Signature of Contractor
ZoOt
J 0 OWNER -BUILDER DECLARATION
W W r` I hereby affirm under penalty of perjury that I am exempt from the Contractor's
1— d License Law for the following reason:
Z( ) 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).
cY) () I am exempt under Section B&P.C. for this reason
NDate Signature of Owner
O0)
d Q WORKER'S COMPENSATION DECLARATION
O 2 Z I hereby affirm under penalty of perjury.one of the following declarations:
CC
O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W LL compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance.of the work for which this permit is issued.
m Q U (. ) 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
cc LO H permit is. issued. My workers' compensation insurance carrier & policy no. are:
t Z Carrier ZURICH AMERICAN Policy No. WC8322096 03
06 5
J(This section need not be completed if the permit valuation is for $100.00 or less).
(. )Pj 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
3 subject to theworkers' compensation provisions of Section 3700 of the Labor
Code,. I shall forthwith comply with those provisions.
Date: Applicant
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.
Dnfe
PERMIT #
BUILDING PERMIT
0204-117
DATE VALUATION. $13,525.60 LOT 39 TRACT 28960
ADDRESS 80-337 SFA MSH BAY'
APN 769-053-004
OWNER
CONTRACTOR/ DESIGNER/ ENGINEER
CENTEX HOMES
CENTER HOMES
2280 WARDLOW CIRCLE, 3= 150
2280 WARDLOW. CIRCLE, SUITE 150
CORONA CA 91720
CORONA CA 91710
(909)279-4000 CBL# 5761
USE OF PERMIT .
RESIDENTIAL ADDITION
ADDITION O 232 S. F. h I 1N-141 P, 101.11 1 11! S C
CUSTOM CONSTRUCTION 232.00 SF
EgnMATED COST OF CONSTRUCTION
13,525.60
PERA4IT FEE SU A&TARY
PLAN CHECK FEE 101-000-439-318 $34.90
CONSTRUCTION FEE 101-000-418-000 $43.50
ELECTRICAL FEE 101.000-420-000 $3.48
PLUMBINQ FEE 101-000-419-000. $6.00
STRONG MOTION FEE RESID 101-000-241.000 $1,35
ART IN PUBLIC PLACES • RESIL 270-000-445-000 $33.81
SUB -TOTAL CONSTRUCTION AND PLAN CHECK
$125.04
LESS PRE -PAID FEES
$0.00
TOTAL PERMIT FEES DUE NOW
$125.04
RECEIPT DATE
I
BY
DATE FINALED INSPECTOR