0204-124 (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
y �
Datef ?� w� Signature of Contractor"
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 theirs.
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 •:a.
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 maintaima 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.
4)_ 1 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 A . t^,p,1,1d Policy No. WCaMP&O
L
(This section. need not be completed if the permit valuation is for $100.00 or less).
() I certity 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,forthwithcomply with those provisi ns.
Date: -}4 Yrs!.>r:?. Applicant '�.b.~ �. t :-1-X
Warning: Failure to secure Workers' Compensatio over v is unlawful and
shall subject an employer to criminal penalties and civil fines upAo $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,' `h , is
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 pursuanf 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.wor06r:1180 :day's will subject permit to cancellation.
I certify that I have- read'this' application and state that the above information is
correct:::1-•agreeto,bomply-with"all City; and State laws relating to the building
:r':constructlorr`;and hereby,authori'ze'rep resentatives of this City.to enter; upon
=' the above mentioned property for inspectlog, purposes.
Signafure (Owner/Agent"' +� • < < " Date`
)
BUILDING PERMIT PERMIT#
-� i
��•�=axe__.
DATE VALUATIONLOT- TRACT
�--4. 2806Q
ADDRESS «r9 nSt°QJOB SITE
APN
OWNER
CONTRACTOR /DESIGNER / EN INEER
cs�
2290 �VIAILY)f fYW CTItI Z MTB1, f,O
12,80 WXe.1:!%rOW. a, Ek 1A SUM, 1250
CORONA. C.k•':, 91124
CUA ONO ZCA. 911720
USE OF PERMIT
Ly-
[:rk'li : x.01' 4r'I�Y�1•J ��. �'.LPP�.�i'i''fS+ti4: r.Y#O'Y' 1'firw:i>iJ'"T�� I�IaP.�t�i�: 'tRl13.D:,l:.�y
``tPCiO S"' OR 6RM?="+h3',#�'jt' APPROAGR
• t.4
CWTOM CONSTRUCTIONPORCHMATE0
SP
10ARAWC.a RPOR7
ESTIMATED CM OF CON1TkITIC'3IAM
20 ,'3146.30
CONSTRUCTION MY,101 -0 04 18.0--00 $1,161.00
PLAN CHECK MIE 500.32
MXCIM131CAL 1 S $11140
L;Y,,Y i'd'F�YC : ;?Yt . 0-11 ••606-420-000 $169.59
PLUMBING FRE 2190.715
a"i`RONO YRx7''3. N VZOV, 101,0004,41-100.0 $24.33
GRADI:i O RE 101-000-42'4-000 $211.00
22,5-/11�pC�0p�MA�j4/,3!-3/42 $ly�,ary0.i+00�
BQT3�{r?�tAy�p31('yi'-Wir-7`/t1[F]./EJ�1p�'{Z 'y]�•7�'
q
.AR Ii}!J:UBLj.dr l-1'ISTi'WALT.YAA:IG..So%�`a'°'L7l)v�"'`7`•P'.7"000 811b�1�3�1
.
,•t
i
r
1=3 Pk9-VAR-) ���'i',
$0.0.0
xt
� �A� �' d4.A.fF�a:�:4.Jt `.1.`.�:.�`�AT .Ed��dl R.;•V.Y
i11�",�. y'�71Y'Y�G•'Jtq
u 3 20 z
C(TYOR AQUIRTA
R CEIPT I)=1
BY
DAT FI ED INSP CTOR
R � ,
INSPECTION RECORD
d OPERATION
DATE 7
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 8 Footings
d
Ducts
Slab Grade
p
Return Air
Steel
Combustion Air
Roof Deck
j
Exhaust Fans
O.K. to Wrap
02, k
_
F.A.U. OK_
Framing
iz3 Z Z
Compressor _
Insulation
Vents
0.0
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lith
S 3v a2-
Final
Final—
POOLS - SPAS
BLOCKWAL
AP ROYAL;
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
0�-�
Heater Final
Water Piping
I Plumbing Final
Plumbing Top Out
I Equipment Enclosure
Shower Pans
Sewer Lateral
Sewer Connection
_T _
_
O.K. for Finish Plaster
Pool Cover
Encapsulation
Gas Piping
Gas Test%
Appliances
-2—
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)
IU123VZUU[ WEU 1U: 19 FAX '. Q006
INSULATION 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 building located at:
r
80-445 Spanish 13ay,Lot 45, La Quinta, California
CEILINGS:
TYPE: BLOW MANUFACTURER: Certainteed Thickness: R-38
WALLS:
TYPE: BATTS MANUFACTURI_R:•Certainteed Thickness: R-13
GENERAL CONTRACTOR: CENTEX HOMES LICENSE #
BY: TITLE:
PARAGON SCHMID BUILDING PRODUCTS, A rv4ASCO COMPANY LICENSE # 632672
TITLE: ADMINISTRATIVE ASSISTANT DATE: 10/18/2002
i -