9903-245 (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
irit>21 i3 3 ``1.13
Date'p�;f fAl Signature of ContractorYv.-t'- f 11`
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).
(•)' Lam 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.
()71 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,- v{ { Policy No. 1�
(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,fo((��hwith comply with those provision
D te: l�)� � � !' CIApplicant''' Z-� 7Vl
"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 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.
1 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 inspectio` purposes. ,1
Dat/'
So i
tVignature (Owner/Agent) �—
,1- l
.. . .. l
BUILDING PERMIT PERMIT#
3445 -
DATE J VALUATION���i.4�i»7iD LOT , �— - w _ .G TRACT
V�J! ,1 �[��/,j l
JOB SITE h
ADDRESS 673 �'�lLROiNA COU W r
J
APN
fd1P fid 4f 9
OWNER
CONTRACTOR / DESIGNER / ENGINEER
'rl 1. EXC.:TAIN :z1"CC.'P
1tS l f'� S 3t:T,;t 1: J1 R i.':.f� <?�ASSOi,."..
i8.0 3'.Nfil''_LX',y DR.
79613 P,AN. � DIUVE
LA Q1.►t('•r: A. GA 92253
LA. CZUIMI"A d,11..41 92'b'i
i 760'17'n-02212, P.{��,.fi 19.E
USE OF PERMIT
SIWLE �tiM11.1'.Li`dvTa�LLIN'<.x.
1,07 44. ri..lii^i 61R. VFD - PE'RNAT i.1l..ES ivEIT rNaCIU.".Wt11 IJ.1,
0R. POILy1". PLAN CHECK K 3�:;fTSit #�� �R7'I°fic.h'Uft-ibt4.TT>`i'.i}'C:I:i .1SSUA,tv(X OF
SAIME, PL. At4 't'y,}I- .
d t�A �tii� �✓i110 ��13� 1��i°i i igf,),�i+� 4y['
KIT2t HAPAXIO 90.00 8F
i ±�Lf4.l4iil^;/CA1Zi'iill�'1' yi}f.b11 :3t�
COId:i1'1i.UC TION FEET 101 -WO -41"W $itt�t►.Utt
}+t. AW Cf-P7("k; '}, rT W1 411(104i 3I, Sg
f0'r.T.tANI. E1I„ME 1.01-000411.000 MW
TXR011tL`,E;AL ME 101-000420.000 $IS7.17'
P1utl149S IN0. FF& 1,01-GCX.i-419-OW 5366.00
SIT!C?t�i%i1u[oT`If1Al{r�F-A��t?(tr If .4W -?41-W) $16",++
GRAY NCI .tom 101.000-•123-004 S210.MI
1NFRMJ'kLil~:TURY1 PVS 2225 (000.443-342 $3,09,4
F KEClISF PLAN 101-0)-441,30 x45.00
ART W JM,'' lBf;TC P),>' C7i , - RIFSTC 701-010-255-01T) P.t N7 T„•
lNQ rif,AN Qfl F C:fi
��r+r+13
LESS
TOTAL PER1v8iT .I C"PS 0t,IE NOW
$5,312.91
RECEIPT ✓}� /"
?GI +tel
DATEL/'I(f
,�I! jj
,
BY
DATE FINALED
INSPECTOR'
a
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs 9
Underground Ducts
p
Forms & Fi;otings
Ducts
Stab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing E
Compressor
Insulation q
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath Z7
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
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
Sewer Connection!
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service fill
Sub Panels e�
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final.
Utility Notice (Perm)
COMMENTS:
JC" -25-99 MOI 1:34 PM Wt:;TFRN iKSULA'PION I"bXA NO. 1r:963i64l5 F. 31
WESTEl N INSULA TION, " INC s F
4211 Latham Street, Riverside, California 92601
(909) 686-8760
(909) 666-6766 Fart
INSULATKIN C�EWIFIFICATE
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:
TRACT/ PHASE: BELLAYVISTA TRACT #: 76412
LOT#: 44
SITE ADDRESS: 43673 VERONA COURT, LA QUINTA, CA.
EXTERIOR WALLS:
MANUFACTURER: JOHNS -MANVILLE THICKNESS: 3 518" R -VALUE: R-13
CEILINGS : ATTS BLOW
MANUFACTURER: JOHNS. -MANVILLE THICKNESS:, 13" R -VALUE: R-38
CEILINGS : BATTSv BLO
MANUFACTURER: GREENSTONE THICKNESS: 10.3" R -VALUE: R-38
GENERAL CONTRACTCIR: ROGER SIN ELLENBERGER
LICENSE NUMBER:
BY:
TITLE: _
DATE:
INSULATION CONTRACTOR: WESTERN INSULATION, INC.
LICENSE NTPd
R: 481278
BY: -
TITLE: ctioan er
DATE: OCTOBER 25,1999
FROM LA HACIENDA NURSERY*LANDSCAPE FAX N0. : 760 342 0768 Oct. 25 1999 01:49PM' P2
..
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