9909-239 (SFD)LICENSED CONTRACTOR DECLARATION
Thereby affirm under penalty of perjury that am licensed under provisions of
Cna.pter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License isin full force and effect. ..
License # 'Lic. Class Ex Date
/ate'�r �'j � Signature of!Contractof or_
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 clothe 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 withlicensed
contractors to' construct the project (Sec. 7044, Business & Professionals
Code). y
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.-
(t&).;
ssued.(t&).; 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 Policy No.
(This section need not be completed if the permit valuation is for. 1l 0.00 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 s.,and 'agree that if I, should become
subject to the workers"compensation prozls�onslo Section`3700 of the Labor
Code, I/shafl,forthwith comply -with thoseprovisions. s
Dale; I (�1"•�..��:f % Applicant••.�—'`�,,��',b�''�.-i"�Ce�--"." .. •
Darning: Failure to secure Workers' Compensation coverage is -unlawful and
shall subject an employer to criminal penalties andcivil fines up to $100;000; in
addition to the cost of compensation; damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees:
IMPORTANT Application is hereby made to the Director of Building and Safety
for, a permit subject .to the conditions and restrictions set forth on his
application.
1.' Each person upon whose behalf this application. is made & each person.at
whose request and for whose benefit work is performed under.or pursuant to
any permit issued as a result of this applicaton agrees'.to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this, application becomes null and void if
work, is not commenced 'within. 180 daysfrom date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction; and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
JSignature (Owner/Agentp''Date
PERMIT #
BUILDING PERMIT _r
— " TRACT
DATE VALUATION LOT'671
JOB SITE -
ADDRESS "• g�
„AtXWC*^
APN
769-2,55,
OWNER
CONTRACTOR/DESIGNER/ENGINEER
CEM'I RY C"PIOWELL CGNS41~:` UIN11
MrWPY CIR
1535 50. "M ISTRE rir., M. 9'200
1535 .SO. "'0" STRE1; L Sn. 0200
SAN BERNA DING C A Q240
SAN BER ARDi 10 , I .CA 9248
0)381-6007. r -.UL# 2.120
1r }
USE OF PERMIT
41NGLE FAMILY d3WRI.L. ING
S ID - LOT 13, PLAN AR,-HIMI' DOEIS NOT INC'f.IME MOM WALL
OR, POOL. 'PLM CRi?r X FEE. REDUCED 951/6 MR MIUME MSUANM OF
SANIE PL401 TYPE. s
CUSTOM CONS fRUc'MN 2,398,00 Si
PORMPATIO .17-6.00 ti°,F
EARA GEICAR1-'C9:1'i,7' . 56ri.00 `ii
,' k A. ft'.13'f ST OF CONS�'�BUCTION :
2flt€;A18.€{0
P ERIAr " FE E SUMMARY
CONSTI?"CTION FM i. rG'3 4MO-41�r' 'ilii6? MUM
PLAN CHECK; FEE SM.I i
•' i
�- • "�7
R iC1irl3?Ii:C i i 'E$iE ... "..:t 01 -W1141-000
E.ECTRIG.RL FUR. 14.00 20 -ow
P.LUM131NO Ef 101 -OW -419•-000 5174„50
} �
STRONG N1011014 FEE -MID 10.1:-W&,24.1-'000
OiRATathiO ME 10.1-000 4,23400 $20.00
DUVE.LOI)ER IMPACP FES � d,sr,cto
ARS' .IN KW.IC PT, ACES - Ri?S5l:: 701-000-2.55--0
SUB-110TAL i;ONS IRUCTION ,AND PLAN C14-EC:h.
$3,810,48
LESS :PRE -PAID PEES
i ES DUE NOW
TOTAL PERMIT FE
RECEIPT
DATE
BY t I f
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
I DATE
I INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
/
Return Air
St
Combustion Air
Roof Deck
Exhaust Fans
p
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
I Al
Final
Final
BLOCKWA'
��s ?�
�. A PROVALS
Steel
POOLS -SPAS
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
OX for Finish Plaster
Sewer Lateral
Z_
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
/
Appliances
Final
Final
Utility Notice (Gas)
ELECTRIC
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)
_
L PPROVALS
loe
COMMENTS:
3
f
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..
Job Name: Tournament Collection Tract: Tr21846 Plan M 3AR Phase: Phase U
Lot No.: 13 Job Address: 55-228 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:
Knee Walls: R-13 Unfaced Batts With Living Above
Interior Walls: R-11 Unfaced Batts Between Floor:
Subcontractor:. OJInsulation Co., Inca
42620 Rip Nedo, Temecula, Ca 92590,
Signed
Tom Berry, General Ma rer-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.