0106-348 (SFD)LICENSED CONTRACTOR DECLARATION
A,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. Cuss Exp. Date J
Date . �,r�� Signature.of Contractorif'� 4�"A "
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 Ahe project (Sec. 7044,, Business & Professionals
Code).
( ) I am exempt under Section B&RC. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirmunder 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. . WC -544068-0
(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: l i.. } Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject Ran 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 of
whose request and for whose benefit work is performed under or pursuant td
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. ;
Signature (Owner/Agent) 1 a �4 1) A Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT Q154}Pa .SAB TRACT
ftm. XASD0 21 24197=1
JOB SITE
ADDRESS
APN
,
! SHAMMA. !C MA ,
'SF(tIp^ r& -m
OWNER
CONTRACTOR/
CON�TryRjACCjT�OpR/DESIGNER/ EN I(�NEER
iwel'.fi.G 1.u:wb A. �' IR i�./'Y'l ' Q�;.�.I•.�v.�c.%V:CY•A�7. U,
7 ��p�}�yd.�+�
L.SS+.ihE 84i�R M0 V'I.{.�,LL 4O.�Vi3Y/af lNI X17 .
133;5 30. -v u a ,Vii£. 4200)
1535 SCS, Me STREXT, ME #200
SANXIFAMAMANO CA 9:U(A
SAX EIRMARD190 CA. 92408
(ROM81-6007 CBMT 2120
USE OF PERMIT
JrMiZ F'AMMY' DWELUNG
300= LOT 21 PLAN 41,?C . PVIMId" DOES 'NOT INCLUDE 1° LOCK,' -WALIJ
1`001, OR 1;11.>VEWAYA3'Piac' ACa 7S% PLAM CHEM V*,' RSflti0T'f0N
APPLIED FOR ME9l.'1'IPIXPLAN TYPES SUBMITTED.
TRACT C0143T11;bCT1.O-N
PORCHIPATIO , 62.014 3F
GARA(;#1(CA.T PdPT 604,00 3-
. 91111 Hal ,ti11<'!1 COST OF CC3nSINU O
1561", 0_1 .
• p .yry���t, l'.��age/�{'f
CrOAOS` RUCTlf',Y.fa ny 101-000.43.8-O DO $939,00
PLAN Cui.wkC Ca`rX 101-00"39-319 39-319 1Ird.I"
I -
1r4; 1 1�h2�tiC:atiil FER 101-000.421.000 �,SO
.1, 1, XC T PiC:A1, F9 N, 101-000-420-000 $133.33
.
PI,UMBIN0 FFIF 101.000.419-000 $142,00
STRONt11e OT1CDNFIr,;a o .i:8.E'SID 101-000-241.000 $13,66
CF1LR,D-510 PEP 1G1-d30gn4713v1100 SAW
�!?4C1�'•Y.:431��t?'k�'11+AaC`1' 1t"�• �1,g7°.1.€it1
fi'lfitro'1'1C1kF AM) PL^S CaTE
$1,316.08
e'1 LESS PRE -PAID P'.t=
PLVW.f +'; 13(30 NOW
$0.00 '
JUN 2 5 2001
•I; rt)'f i/{1 Qll%JIi°r•I�fo�l
—
BY
r
DATE FINALED
INSPECTOR
1
I�
INSPECTION RECORD
I
OPERATION
DATE
I INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
Underground Ducts
Slab Grade
_ (
Return Air
Steel
30� - -
Combustion Air
Roof Deck
`
Exhaust Fans
O.K. to Wrap
_ _
/� _ _
F.A.U.
Framing
�d!
Compressor
Insulation�
Vents
Fireplace P.L.
Grills
Fireplace T.O.
'r
Fans & Controls
Party Wall Insulation
Party Wall Firewall
Exterior Lath
_ i
_
Condensate Lines
Drywall -Int. Lath
,I
if
Final
Final
?, �- `v'z
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
n
Electric Bond
Footings
i
Main Drain
Bond Beam
Approval to Cover
!
Equipment Location
Underground Electric
I
Underground Plbg, Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
l
Heater Final
Water Piping
i
Plumbing Final
Plumbing Top Out
!
Equipment Enclosure
Shower Pans
1
O.K. for Finish Plaster
Sewer Lateral
y
Pool Cover
Sewer Connection
6,2 �`�5
Encapsulation
Gas Piping
Gas Test
Appliances
Final
i
,f
COMMENTS:
Final
Utility Notice (Gas)
I
ELECTRICAL APPROVALS
Temp. Power Pole+cam
q
Underground Conduit
Rough Wiring
Low Voltage Wiring
it
Fixtures
L
Main Service
Sub Panels
4
Exterior Receptacles
G.F.I.
Smoke Detectors
!
Temp. Use of Power
l
it
Final
i
Utility Notice (Perm)
s_ p
�v
12!12/2002 THU 13:29 FAX
INSULATION CERTIFICATE
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 the building located at:
79-806 Shadwell Circle, Lot 21, Monticello -Heritage, La Quinta, California
CEILINGS:
TYPE: BLOW MANUFACTURER: Certainteed Thickness: R-38
WALL
TYPE: BATTS MANUFACTURER: Certainteed Thickness: R-13
GENERAL CON RACTOR: CENTURY CROWELL COMMUNITITES LICENSE # 744181
BY: TITLE: 14i
r
PARAGON SCHMID BUILDING PRODUCTS, A MASCO COMPANY LICENSE # 632072
Q
B TITLE: ADMINISTRATIVE ASSISTANT DATE: 12/1212002
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