9909-244 (SFD)LICENSED CONTRACTOR DECLARATION
I -hereby affirm under penalty of perjury that I am licensed under provisions of
Chapt@r 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
i
7141.98
Dee , _ _ A . ,(AV -1).
Signature of ContractorA WAX.
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 workfor which this
Permit is issued. 'My workers' compensation insurancecarrier & policy no. are:
Carrier Policy No.
GOLD n1l EA01,131 MS. U4068-01
(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 and agree that if I should become
California,i ±r, r
subject to the workers' compensation provlslotns of Section 3700 of the Labor
Code, I shall forthwith comply wit ilhose pro�lslons
Dale: 1• f/ Applicant. •r• .k� Jf".n:
,v A . �.
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 purpoo•Ises.
f
Signature (Owne'r/Agenn jY` �, �. 00ate i0k- �
BUILDING PERMIT PERM
OAT VALUATION LOT , TRACT
/� �[ �f
�Er
JOB -SITE
APN
ADDRESS.`55=138,>i•lNtsI:lMOOD
��A r I
OWNER'
CONTRACTOR/DESIGNER/ENGINEER
CENI'UP Y ;;.RO'%rELL C4aEv MiJNITII:S
CEMRY CROWL LL Ct;J1 N,9JR1T1ES
1335 SO. " Lig" 'TIRE E7' M. #200
1535 SO, "b" "'i'I E r, S'A`E. 42M
`a'.AN BERNARDINO CA IV2408
SAN B?Bfi2=itlRr'31trO. CA 92408
6 +i1� Jir3i-bQ07 IwBU 2120
USE OF PERMIT
SFiD -LOT lfi, PLAN2R, - POttaiT iDOI 3 NOrT llqCi Wr,, BI,OCii ''VAi-L
OR POOL.'PLAN CW. K.FEE REDUCED 7V/6 FOR M;3'4IRPLE ISSI.fa1:MM OF
SAME PLAN T'A'PE.
CUSTOM CONSTRUCTION 2,V4.0Q ,SF•
PORCHIPATFO. 196- :it
GARAGWCARPORTT. 1507A0 SF
'a 'r � cra, d4ONS KUMO
E'.1tLR,11'1n ME •SUMYYIr' RT
CO?+T4fi}Z:43CTION FEF 101--iDW418-0$937.tift
V
I'I:'1.NCwi 'l::rk 5 $19:1.533,
�.4
IM-C;ilA}=iiC At, FOE 101. �=-Q 1-0'00�.
9 i.P. n?ui :Ai. PEE 101-0%420-000 r i+1<54. ��
s I ;, �w :
1TI.IAMIF G FSE 1.01-000-119,000
� t
tmio 1v1)TION Fl - RLSID . 101,M),241-000
GRAD1NO F"EE 101---423-000 �2 .tDes
„� ►
1)E'ii7sLOf'3;@i..OVACI F"1"FS
Afrr .iriiPML1C PLACES • R&91b70.1_000 W_0(yJ 19
' SUB-TUE9AL C��/1`i �,,311.V1.'.I J.}r!�)I-"SND .P1x�t.L7 � dS.4:r.['!
$3,70.3-06
LESS "P•t &FA1.Y).0-Ew
$0.00.
TOTAL PLRM.111 FEES DUE, 'd NOW
S3,;i4D�.IRte .
f . A -i
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 4F.A.U.
Framing ,(6Compressor
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
BLOCKWALL APPROVALS
POOLS -SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I I
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 ST
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fodures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
Certificate of Insulation
Your Home has been insulated with CertainTeed Fiberglass Insulation products, which are designed ,
for today's safety standards and tomorrow's energy requirements.
Fiberglass is inorganic and therefore permanently noncombustible, so it does not have to be treated
with fire -retardant chemicals that will likely lose their effectiveness over time. It has not been treated
with chemicals that can corrode wiring or metal. Fiberglass will not absorb moisture nor will it
settle over time as may other insulation materials.
This also certifies that CertainTeed Fiber Glass Insulation has been professionally installed in this home
to provide the following thermal performance..
x
Job Name: Tournament Collection Tract: Tr21846-2 Plan #: 2BR Phase: Phase H
Lot No.: 25 Job Address: 55-012 Tanglewood
Ceiling Area: R-38 Blown FIberglass Garage Ceiling: Non Access:
With Living Above & Sloping Areas
Exterior Walls: R-13 Unfaced Batts
Overhangs: Access Attic:
t Knee Walls: R-13 Unfaced Batts With Living Above
Interior Walls: R-11 Unfaced Batts Between Floor:
Subcontractor.. OJ insulation Co., Inc.
42620 o Nedo, Temecula, Ca 92590'
Signed '
Tom Berry, General Manager- Temecula Branch
R- means resistance to heat flow. The higher the R- value, the greater the .insulating power.
Ask your builder for the fact sheet on R-, values. Keep this certificate with your other
valued papers. If you ever sell this home, this certificate should be passed on to the buyer.