0112-051 (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
75r 4 OP.4 A_R Cr+ 1/03
VlDate t = (t Signature of Contrctoi" �'`�
OWNER-BUILDER DECLARATIONa
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 ofthe property, am exclusively contracting with licensed
contractors to construct the piioject• (Sec. 704.4, 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 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.
(vQ 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:
Cartier-ZUIUC:_.P.�3+�d1Gia1C'.FA4 Policy No. 9s�C23?2Q312�i-®3
(This section need. not be completed if the permit valuation is for $100.00 or less).
; ( ) .l, 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 prow slo §.
/Date: +,», � Ohio Applicarit',.' r
Warning: Failure to secure Workers' Compensation o era' is• unlawful and
shall subject an employer to criminal penalties and civil fines up)t'$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. t
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 • ;f,
construction, and hereby authorize representatives of this City to enter, 'upon ..
jthe above-mentioned property for inspection purposes.
Signature (Owner/Agent)-T '""*� `-="'~ Date
BUILDING PERMIT PERM T#
DATE VALUATION LOTr-yq TRACT
i�7F!,797J'14
) �. a€��FrO
JOB SITE
APN
ADDRESS"
OWNER
CONTRACTOR/DESIGNER/ENGINEER
�:,,at"i���I�Go'f�:�3-i9.'7L+�I'.�9:i7..��l�►i�li�TC'1�
�1'k�;I:li�i3 '
3�. 011V �J / C,"i13G ti 3` 134D
22,80WA.iDLOW C°!R= 3UMI 150
CORONA CA 91720
CORONA CA 91720
(M9)2,79-4000 M41 576
USE OF PERMIT
SK) - L•t.Xr 74 PLAN 3111,. PER141T DOFZ NOT INCLUDE H.1DCK WALLS,
P001 APA OR DI13VI!WAY APPROACH.
CUSTOM CONSTRUCTION li,20100 OF
POWMI RATIO 53i•130 sp
0�b1RAC"s?�.�CATOORT 448.0 S'I'
MUM= Crosir OF Cf)>;+iRIMIXIM(M
271,7970)
C'ON TF OCTIO% ME 101-V00-418.000 $1,241.M
PLAN MHECK FEE 101-000-4394318 81,009.41
�t�i�?•I•IO,.'l.I� .� l i? a �Ci�4 2. i ••4iS0 $ 31#f,Ct�
PEP. 101-t20 IS20.000 $176.44
PLUMOMO "tom, 101.0004,19.000 $I92.50
S�TR..t'��nI��CO�sip1���C>p�TIONkms•_. ID 1,011-}00{0!•241-0.00
@$ry2!'1,.p181
.�.Jf74.CJ..DMO B"i:S 4 01 ,000-42.3, HVoo 5201 0.
,ART M F7L±s9.,FC FLU.'es " RMIT 270-0004145-000 $179.49
PUB-ItYF:'AL. CC)NTtRM"1 ON piS Pi"'Cli,:K�
,01.52
LO PRE -PAD FM
(q
N.OIi
TMAL PFRWX IMM DUE NOW
RECEIPT
DATE dz%u..
B1C%'
DATE
NA E
b�
INSPE O
IgI
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings��01//L
_
Underground Ducts
Ducts
Slab Grade
'S VY (,L
Return Air
Steel
Combustion Air
Roof Deck
_ _
O
Exhaust Fans
O.K. to Wrap
�_. ,
F.A.U.
Framing
��p% rte..
Compressor
Insulation
.yG/��
Vents
Fireplace P.L.
Grills
Fireplace: T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
_
Exterior Lath
S 9 D 2
Drywall - Int. Lath
Final
Final
_
��"l�— -
POOLS -SPAS
BLOCKWALL APPROVA
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
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
(o
Final
Utility Notice (Perm)
,06./20/2013 21: 31 RAX
oil I
L
INSULATION CERTIFICATE
This is to certify that insulation has been installed in conformance with the cucan-ent energy
regulation, California Administrative Code, Title 24, State of California, in the building at
80-9S6tpanlsh Bay, Lot 73, La Quinta,,,California
CEILINGS'
TYPE, BLOW MANUFACTURER. Certainteed THICKNESS: R-38
WALLS:
TYPE. SATTS MANUFACTURER: Certeinteed THICKNESS: R-13
GENERAL CONTRACTOR- CENTEX HOMES LICENSE# -
BY:
PARAGON SCHMID BUILDING PRODUCT'S, a MASCO Company LICENSE #221517
BY TITLE: ADM IN ISTRA71 IVE ASSISTANT DATE: 8113!02
_,�
INSULATION CEWIFICATE
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 !he building located 2!
80;467 Spanish Bay, b 74, 1 California
ot
CEILINGS:
TYPE-: BLOW MANUFACTURER-. Certainteed THICKNESS: R-38
WALLS:
TYPE: BATTS MANUFACTURER: Certuinteeld THICKNESS: R-13
GENERAL CONTRACTOR: CENTEX HOMES LICENSE
BY: TITLE:
PARAGON SCHMID BUILDING PRODUCTS, a MASCO Company UICENSE #221517
TITLE: ADMINISTRATIVE ASSISTANT DATE: 8/13102
1�