0106-344 (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�•
ate " Signature of Contractor`'—'k) "°� - ✓
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, at owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business &. Professionals
Code). V
() 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'3700of the Labor Code, for the
performance of the work for which this permit is issued.
S%I have and will, maintain worked compensation insurance, as required by
lion 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 $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
Co,,de, I shall forthwith comply with those provisions.
Date: �� •/00 :, Applicant^...W...,,,,.,,
Qi�'�'��^":1N ^��Cn �� �.+d �,r,.I�.1� � I"+.:-�•Sfirn .- s•L.✓b�
rning; 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 purposes. t ,
S,nature (Owner/Agent)i./r��� f"4 + r t- d Date'
.BUILDING PERMIT PERMIT #
DATE VALUATION LOT MW344 TRACT
a< a- 17 241, '
JOB SITE
ADDRESS
APN
OWNER
CONTRACTOR/DESIGNER/EN &NEER
CFWSY.MY CRE'1WnL_C0i,1!EIaf.1iJW11 -
UMMIRY C20WAIL COMMUNMYS
1535 30. 'D" UrM93T, STE #200
1535 sa -DO 33'x' mrr, nz a2Ufl
SM 131,1MMUNO CA. 92408 '
SM BERHA1ZTJN0 CA 92,4 8
USE OF PERMIT
3F0 • 't10T 17 DYLAN 41PAR •. PERMIT DDIs.-3 NOT INCLUDE «3I..C1cx 'Erii'AL ;., .
POM OR DRNEWAV APPRK,9ACH. 7.6% PLAIN CHEM T'fm mucrow
A3A'I'IJZV KDA 8A.t3L,`C1'lal:,Z PLAN TYPES 511NIMITTED.
'l"R14, Y,MNST]w`tIICTION Uftn Sd+'"
POkCWPA IO 63.01D s?
CSiARRA,MEMA iiT ON
t1F►'�' ji�3 �;� 43 �:t AI�S(`C3�'d.akr►,..X3
'
:4?PHIR..Wr M RUWAARY
CONOT RUCTION M. 103.000.418-000 $930.00
PLAN CHPA'K IRE 101-000439-:318
MECHANICAL FM 101-11100,421 -000 $60.50
lrtrr i:i'rucv, P.m 101-000-420-000
P9,:UMI3T O FEE 103-000.419.000 314100
`
STROidf;& MOTION FEE - "WID 101-000-241-000
4KADIWO FEE 1(iln'000-4L04.>000
D,Z'VFA,OF'L,it I3v3RACT l'.GE �I,9fs't 0f3
r'J^U
J-=-
t'ftt'3CTiON A X3 nm famCK
X 3,;3 16.08 . ;
1"S M-PAMEMS
MOD
J U N 2 5 2001 Imam DUE NOW
CITY OF LA OUINTA
FINANCE DEPT
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
TINSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
`�j _ _
<�
Underground Ducts
Ducts
Slab Grade/
Steel
// -' — d/ P_
/
ReturnAir
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
_ _
F.A.U.
Framing Dz%� _vL
_
Compressor
Insulation n —
Vents
Fireplace P.L. L
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
��/����
Drywall - Int. Lath
Final
Final
2 /9-0 �D
POOLS - SPAS
BLOCKWALL APPROVALS
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
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
`
- 11T`,
l_7114--cm-
Utility Notice (Gas)
ELECTRICAL APPROVALS
ELECTRICAL
'Temp. Power Pole
Underground Conduit
Rough Wiring
-
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
7 / O
Utility Notice (Perm)
12/12/2002 THU 13:26 FAX 16007
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INSULATION CERTIFICATE
% This is to certify that insulation has been installed in conformance with the current energy
regulation, California Administrative Cade, Title 24, State of California, In the bullding located at: .
r ,
79-757 Shadwell Circle, Lot 17, Monticello -Heritage, La Quinta, California
CEILINGS:
TYPE: BLOW MANUFACTURER: Certainteed Thickness: R-38
WALLS:
TYPE: BATTS MANUFACTURER: Certainteed Thickness: R-13
GENERAL CO RACTOR: CENTURY CROWELL COMMUNITITES LICENSE #
BY: TITLE:
i
PARAGON SCHMID BUILDING PRODUCTS, A MASCO COMPANY LICENSE # 632072'
TITLE: ADMINISTRATIVE ASSISTANT DATE: 12112/2002
.. '7iY.:!„>%Y,.%%:.::+•/1%:ry,;•.-;'n'%ri'.:/r.%:::>Y� i::"+r/,=/.:'n37.0%•:%F7e:G'; /.:.e: G:-:N,::'Li%eiw,:iY'✓J%if_f%AriN..1.:•N::::n.IY•5:d::ib^'n'.:f/.Ja iw %N7Jr'/ %' r:.'%s".]9::C/.•i %Ylrv'%V%'lJ :}%O,:u:..:.iYO:%'/ %�dll/i'. � ::?%'lI/i%T/iJ