0106-349 (SFD)LICENSED CONTRACTOR DECLARATION
'1 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 /'':;�.j�% Signature of Contractor
C
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).
( ) 1, 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.
6xCiIa%MI MIX flis, VWC•" 00.0;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 provisioQ a
Date: 1`/ r -'/P% Applicant J ?;"'3-s
yu t
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safetya''°
for a permit subject to the conditions and restrictions set forth on his',
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days -from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes. 7
Signature (Owner/Agent) >3T_t(rTf+�. Date4'/'
BUILDING PERMIT PERM T#
DATE' VALUATION LOT TRACT
I S1, it . C9 22 24197-1
JOB SITE
ADDRESS
APN
'7�.oA4nv a`h�.A.�� V4�Lf,MAt L..A,ia�,Y.�nJC�.
� I.fil^��y9ib
OWNER
CONTRACTOR/DESIGNER/EN INEER
1535 iii. 41Y IrMIT, ua'.€7, 4200
15358, 0, V VIRKET, M 0200
SAN BEMARID1140 Cdr, V2409
RAN ° BUNARDINO CA. 92,408
`4 053 )381-6007 taI MAY 2120
USE OF PERMIT
Std} « WT .12 P,L AN `iHR • PERMIT OLKS NOT INCL,>i M BIi,DL:lC; WALL,
POOL OR DR'fil'FWAY APPROACH. 75% PLAN C I.0))'K FEF REDUCTION
APPLIED FOR MLIVYIPLIK PLAN WPM SIJRMl`2"!'M
'.3'1tE1CT CONSTRUCTION UI x,00 SF
PORC`> 1IPA 10 , 29.('ell EF
GAR &OWC.t'i,RPOIR't' 623.00 2R
EgnmN= COW 01FCONIMNUCUON'
13V1020
CC+NTPRUCTION WE 101 _000 -418 -ow M11100
MM CHECK Ftrl$ 101-000-4.39-318 31 0.1 I
M&C.FMIC4.1 FEE '.101.001)-421.000 350100
91.4CTRIGAL 9 101-000.420-000 $139.53
PLUMBINOTye 101-000-419-000 $124.00
SP12. 1111 1 M011ON FEE,, RES1Ll 1.01-000-242-000 $13.39
GRADING.0;,F $20,05
DEV EWPk It JNIPAC T FES
AATI3 Pa..AW CHECK
IM9 PRE.-PAD)1 EES
JUN 2 5 2001 L
CIPY OF LA OUINTA
FINANCE
RECEIPT
Y
' a
DATE FINALED
INSPECTOR
it
INSfPECTION RECORD
OPERATION
DATE
,INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
Set Backs
Forms & Footings
Slab Grade
Steel
Roof Deck .
O.K.to Wrap
Framing
Insulation �M���
Fireplace P.L.
APPROVALS jj
/ /'//
` B�U� fl/C�
17_ _ _
7
/jS/ _
�77U[)� _
�6�2`D
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
"_
10747_W
Drywall - Int. Lath
;(
if
f
Final
Q1
Final
POOLS - SPAS
BLOCKWALL
APPROVALS
Steel
Set Backs
If
Electric Bond
Footings
II
Main Drain
Bond Beam
i
Approval to Cover
li
Equipment Location
[
Underground Electric
Underground Plbg. Test
Final
l
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
f
Heater Final
Water Piping
}
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
If
O.K. for Finish Plaster
Sewer Lateral
I
Pool Cover
Sewer Connection
Gas Piping
1G_
Gas Test
Appliances
I
ii
Final
}
COMMENTS:
-
I
Final % �z
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole' 1
Underground Conduit
Rough Wiring {
Low Voltage Wiring l
Fixtures }{
Main Service i
Sub Panels I
Exterior Receptacles it
G.F.I. [
Smoke Detectors [
Temp. Use of Power I}
11 "
I{
Final
Utility Notice (Perm)
H
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:
79-820 Shadwell Circle, Lot 22, Monticello -Heritage, Le Quinta, California
CtILINGS: 7
TYPE: BLOW MANUFACTURER: CERTAINTEED THICKNESS: R-38
;WALLS:
TYPE: BATTS MANUFACTURER: CERTAINTEED THICKNESS: R-13
GENERA CONT CTOR: CENTURY CROWELL COMMUNITIES LICENSE # / l
BY: TITLE:
PARAGON SCHMID BUILDING PRODUCTS, A MASCO COMPANY LICENSE # 632072
TITLE: ADMINISTRATIVE ASSISTANT DATE: 12/12/2002