0204-120 (SFD)t' 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
34 094 F:�' ✓
Date Signature of Contract0"r`V_2"
a � `
'~ 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.
e ) 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 ZURICH AMEE cAN Policy No. Wf X11122W-03
(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 shall forthwith comply, with those provisions....,,
Date: i`i iJi A li'65M � ,Y
Warning: Failure to secure Workers' Compensation coverage iszunlawful 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 ort'�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 y
any permit issued as a result of this benefit,
agrees to, & shall, inde i t'
& hold harmless the City of La Quinta, its officers, agents and employ
2. Any permit issued as a result of this application becomes null and v
work Is not commenced within 180 days from date of issuance of
permit, or cessation of work for 180 days will subject permit to oancell
I certify that I have read this application and state that the above informati n -is
correct. I agree to comply with all City, and State laws relating to the bui ing
construction, and hereby„authorize representatives of: this .City. to: enter .pon .
the above mentioned property for inspecti n purposes.
Signature (Owner/Agent)% IN Date d
PERMIT #
BUILDING PERMIT
S- a -_--_*%
DATE VALUATION �.ryr� q r��•yp�� LOT— _ -
tB6 ! 8p !:•� f sG+'V i�:{G TRACT
” `.✓ 'dei f.'T.
JOB SITE
ADDRESS - .�E'p�►-�Y
APN
J'3-�3^«"
OWNER
CONTRACTOR/ DESIGNER/ ENN INEER
cola": 1,10h1:i.d:+A3
2280 WAVJ3WW CIEW12.1 12.1 BUTT. 150
22180 WARDLOVI CM -U!, SC M1, 150
COR.69A .,A. 91,120
0,MONA QA 9172
r '
LyV),ri9 400€9 ' . Y, t "761
USE OF PERMIT
SM. LOT 361 I.AA14 31 L W. MINI-SU.ITL RX?MIT-DOI�..„�°,'i NOT _
WIMP. W)CK WALLA POOL VA OR i3RUV EWA APPKOACH
CUSTOM C OINS'3'Y UC,`TION %28100 8F
V101IC'%I9P.ATIO 335.00 V
G.Ai"..d3OTUC:ARPOR.T 449,00 8F
F11l'11'OWIM) CIO F OF C01110TRUC110H
271;797.80
CCyX;t' H:UCTION F,EE• 101' D00.41,S-000 $1,241.50
PL.\23 CI^FF.CK =I 10r -'000A39-318 $i'00.41
M1CI4ANIC;l L FEE 101 W! -41'.1,000 $115,413
LI,f VRICAL FEE 'W4" 0-0p.0
P3..UM14 KO VEZ 101-000.419.000 $102,50
1CTgqY
fsy[$►►fr`pp.C��3yy2�GY ��Yd[�IC��7jj1rfC�Ai'l�'D,;<�•12:tR<�D3c�
gd•��{��b♦♦i��-f((��?C��iJ�Lyy►
ORADDRY CRE 101-000,423-000 2N.vW
INIMA,Su'i'iIIJC'it)PJP 221.000-443�342 0,907,00
.AttT :TW PUBLIC PIACM - RESSIt 279.000-445-000. $179,49
i.
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SI.413-1, C 0.14 i,: �)'r`° €iON 9 fi.PL K CTI CK
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MAY 0 3. 200Z
ITYOFLAQUTA4TA
FINANCE®EP7
RECEIPT w
DATE ' z
BY gg
PE
rWINALfflbl SV.
;k,
INSPECTION RECORD
- OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Slab Grade
Ducts
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
OX to Wrap
pZ
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 l
— -
BLOCKWZ 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
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
S �7 t57i _
Encapsulation
Gas Piping
Gas Test
Appliances
/
` /�
7111
, ///
Final
Final I JI (7
-----
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Law Voltage Wiring
/Fixtu�I __s
Main lWSenrice i —� /..__7Yr
COMMENTS:
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Notice
I. U/ ZJ/ZuuZ ncu IU zu r,A.x UU07 .
INSULATION CERTIFICATE
This is to certify that insulation has been Installed in conformance with the current energy
reguiation, California Administrative Code, Title 24, State of California, in the building located at: 1
80-364 Span is I� Day, Lot 36,7 -La Quinta, California
CEILINGS:
TYPE: BLOW MANUFACTURI=R: Certainteed Thickness: R-38
WALLS: �+ '
TYPE: BATT:> MANUFACTURER: Certainteed'Thickness: R-13 i
GENERAL CONTRACTOR: CENTEX HO IES LICENSE #
BY: TITLE: `
PARAGON SCHMID BUILDING PRODUCTS, A MASCO COMPANY LICENSE # 632072
BYE_ TITLE: ADMINISTRATIVE ASSISTANT DAVE: 10;16/2002'