9910-184 (SFD)LICENSED CONTRACTOR DECLARATION
y I hereby affirm under penalty of perjury that I am licensed under provisions of
"f" 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
ffect. License # Lic. Class Exp. Date
6971,17 8 ton 1/201
Signature of. ContractoP*1
OWNER -BUILDER DECLARATION
I hereby affirm under, penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1, as owner.of the property, or my employees with wages -as their sole
comp ensation,.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).
O I am exempt under Section B&P.C: for this reason
ate.. 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 f6i by Section 3700'of.the Labor Code, for the
performance of the work for which this permit is issued.
(NSI 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.
STATE I 1N.)
(This section need not be eompleted1f the permit valuation is for $100.00 or less).
(') I certify that- inthe 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.l shall forthwith comply withth se rrov�Jdons. t "
Dal I to 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 Fiis
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,'br cessation of work .for 180 days will :subject permit to cancellation:
I certify that I have read this application and state that the abov6'inf6rmation 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 ppurpopoosses,-
SAg?t-�fure (Owner/Agent)'/ +�I Date
BUILDING PERMIT PERM'T-:
DATE VALUATION 9°�°�ei��- LOT TRACT _ • ,
JOB SITE�v�p+p +• ` , APN 'I
ADDRESS 794 Ltt►i�LE NIUS.,L
OWNER CONTRACTOR / DESIGNER / ENGINEER
CET,Ih'H.4I�3 , AND VVILUMIS ASSWIy HMO_
77-900 AVENUE &F` TRE a'TATES `... 77-900AVENUE Of! TkIE S''!'t#T'3
pA.I.i� DE.:SEW1' .OA. _42'211 ;i'Ai:,i8''DESER.T .:,A. 92,211
(740)345-2626 CMU •520.1
USE OF PERMIT
SINCH,2 PAMUN DWELIJNG
SFT).• ]JOT $6, PLA14 .IA. j'.►s UMIT WES NOT NCLUDE, g.L -1A1AU"; 0R, '
TRACT 1;,0NM'RD*N-1i $.G14 1,736.00. SF
PORCHMKI10 58.00 5F
ti3;r1Rto019S':FI":lAC.1RT 4'SYi.tsU SF
.{��,`.ryA•f
104. P5I,30
•. M� S.'JRA��O fi �,> EE CV Dl.1W.N,1,'lt t9KV
�p.Ty',� � ,�
yy gg;^ ;;��� ,,yy". FEE
CFS:)F?ti flbUt".:'t'i('3N-FHE 101 -WO-4184)00
PLAN Cffl3Cl5 FTE
$47,00
J ,(
r-I-ECIR C AL $138.18
C.)
PLUMBING P'
S"t'RQiNf3MOTION FwG - mF;SYD
GRADING F.Mal If01••i,1C1(i••4.^3-'Q�
ART 1N Ktt3i.aC KA!,' %S'- USIL 701 -000-255-" S11.89
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��i:art=�;�'�'t�%����:'h.1?�.`�'�i:�1ti.A.��:.► �:�:��N C a��E�;��,.
���;.�y:3.���
LI S S PRE -PAID VET.-
` f :b" .00
$ i? 'AL,'6<;1F f��. tc t'. b' A13'1i:?�i�3W ..._
S3.493M
RECEIPT <
DATE'
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
NJ
Combustion Air
Roof Deck_
Exhaust Fans
O.K. to Wrap
—00
F.A.U.
Framing
Compressor
Insulation
l
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
- ► LOB
Drywall - Int. Lath
Final �(�
BLOCKWALL APPROVALS
Final
POOL`S - SPAS
Steel
Set Hacks
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
12 2I
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
°z — P
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
(r • 3� -
Appliances ,
Final
COMMENTS:
v
Final
Utility Notice (Gas) �� C
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 ((yJ
Final
Utility Notice (Perm)
N
m
- Cerfifficate of InsOki'on
- m
Your Dome hss beets insulated with1 Ced�ain�Teed Fiberglass i�ulatiaa pn7�rcts, which aze des�gµed
1,
_ • for UDWs Safety draft& wd tomarra Ws Mow CwHremeals,
m
- , Fibergla59 is iunrpaic and ffi=fure perrianenZly noaommhvSgbte., so it does not have oo be seated
with fit �ricals Heat will Iikelp lose Wray effeotiveaess over iime [t bas sat been nr�ted
o
wbh chsmicaU that can cnrrode wmng or metal. Frbeaglass will not absorb maisb= nox wdt it
settle aver time as may athw iasolatian mat iais,
•
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Ln
'hs also =fifes that Cm=nTaed Fiber Class lnsaftm has been gm5maaaliy i ga&d im thus home
to provide the folldwing thermal pedDrm um.
D
Jos Name: Snnrien Tract 15453 Plan #; I Phase: 3
z
Let Na; 56 Job Addmm 79426 Calle SonriBa, IL; CA
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Cea7mg Anes: R-38 Uat=d Garage Co ing;
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With Living Above
kn
Interior Walls:
Rzgwior Wade• R-I3 Unhwed
m
Party W��h Above
� .
�Iyavi�ng
(y lWall
en) CeUmg
Ln
-SUbCOM&OMr.. OJlnsulWftr Co., Inc-
F 6Q03 AYact 2-h 91702 (00892-4070 11cenw0",S709
Stgaed
Conchka &*1 S`ecrefary/Tireasrerer ter-- A SCOW denhhzs, P�neWent—or—
V
Lou Mewls, Directair of Opemdons Offlcer
R-n=w reshum to heat -2m. The higher the R value, the greater the Wn daoing power,
• Ask your builder for the fact sheet on R- vale= Keep this cmtwcwc with yaur other
o
vahwd papers. Ifyou ever sell Mie home, this MAfflcft should he passed au to the buyer..
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