0106-341 (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
Date /Py'" a; '� Signature -of Contractor I_,�t
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 work for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier . Policy No.
ca��,�ii?:t� 11.4'aOl}� Yld°., ' ��C�S�-�t]f�`�•$i;3
(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
Code, I shall forthwith comply with those provisions.,,
Date:tk..,= Applicant
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 p
whose request and for whose benefit work is performed under or pur
any permit issued as a result of this applicaton agrees to, & shall, in
& hold harmless the City of La Quinta, its officers, agents and e
2. Any permit issued as a result of this application becomes null and id if
work is not commenced within 180 days from date of issuance Lich
permit, or cessation of work for 180 days will subject permit to canc I ion.
I certify that I have read this application and state that the above inform tion is.
correct. I agree to comply with all City, and State laws relating to the b ilding
construction, and hereby authorize representatives of this City to ente upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) r)S �`�`i'�'- Dater
BUILDING PERMIT PERMT#
DATE VALUATION LOT 401.06-341 TRACT
$176A2,830 lib 24197b1
JOB SITE
APN
ADDRESS V -7W RHADWF.LL MRC;LE
724M
OWNER
OWNER
CONTRACTOR /DESIGNER /EN 1NEER
17EMI-EMY CROMEEI. CL4C
CLRY own -,L commuka4;
15:35 30. 11)° M21.'FEKV, M-1, #200
15,45 $0. A.)° ISTEE T, ME #200
Wd BERM.AKDR40 P_k 92/408
SAN BERNAP13.190 CA 92A08
�c�2 ys$1.13(x)7 MEIN 2130
USE OF PERMIT
SIS " [,OT 14.PLAN 5AR • PFXM1T rJOFX NOT f1 CLUYX 0LOCJ('XAL1,
FOOL Oft DI&EWAY APPRO,AC.H,
TRACT CONSTRUCTION 31012.00 S.E+
PL)RCHIII .TIO 35.00 Sys'
OAUOElfyAitFORT 6.41,00 SF
MAMA= C.`Ol-" M OO.Er3S.11tR7''MON
176,428,10
CONS'x11.t. CTION ME 101-000-4118-000
KAM C HECX F' 101-00(1-439-318
MsEO;E4.&NIC'.1 L FEE 101-000.421-000 $e9100
ELECTlr'1t~"A' L FEZ M -000-4204M M V E 7b,
PLUMBING."19 101.000-419.000 $101.2.5
VIR(M .PCO f ION YU, - RMI i3 r`, 64
(3R.A0?AI4:1FEE 101-000-423-000 380.00
IiV9EWPER bHdlPAl:T PY.F. $J}907 00
SUB J, CO1 MIaCY1l01T siNf>'x'x., LACK
€1:4,012.29
L �1
IYA`3 �']3L�i�"�, EMS
$0.00
JUN 222C01 TMAL PF.�a1 rKES DUE OON#
CITY OF LA OUINTA
FINANCE DEPT
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs _ _
Forms & Footings _ ��
Underground Ducts
Ducts
Slab Grade
_
//�—+
Return Air
Steel
Roof Deck 9�/
( _
Combustion Air
Exhaust Fans
O.K. to Wrap
.p;
F.A.U.
Framing ZZ l
Insulation
Compressor
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final Z _i . C9 a
Final
2. —
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 i
PLUMBING APPROVALS
Gas Test
Waste Lines
�j,�/� /
Electric Final
Heater Final,
Water Piping
/ /
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover 1
Sewer Connection
, /S ,�
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
Final
Utility Notice (Perm)
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INSULATION CEILTBFICAII'E
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This is to certify that insulation has been installed in conformance with the current energy
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regulation, California Administrative Code, Title 24, State of California, in the building located at:
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79-799 Shadwell Circle, Lot 14, Monticello -Heritage, La Quinta, California
TYPE: BLOW MANUFACTURER: CERTAINTEED THICKNESS: R-38
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WALLS:
TYPE: BATTS MANUFACTURER: CERTAINTEED THICKNESS: R-13
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GENERAJ CONT CTOR: CENTURY CROWELL COMMUNITIES LICENSE #
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BY: TITLE: �st4•�c�USfIL�'
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PARAGON SCHMID BUILDING PRODUCTS, A MASCO COMPANY LICENSE # 632072
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BY: TITLE:; ADMINISTRATIVE ASSISTANT DATE: 12/12/2002
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