9910-186 (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
FIW6881011alS Lode, ohd my LICense IS in Tull tone and effect.
License # Lic. Class Exp. Date
D' ! /01 Signature of Contractor
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&RC. 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.
N) 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 �t trND Policy No.
SfA
1126
(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 s all forthwith comply with those pI; visiojis. ^"
DNe: f ° PV 'IV Applicant
"���L �4-�` �`.�C. .�r,
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.
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 pWu .poses.;
✓�f / At J x
SIbijZture (Owner/Agent)" �� '� Date ✓�'
r
BUILDING PERMIT PERMITk
DATE I �� VALUATION `5�,�!`,tm`;,1�`�4�� LOT
_ TRACT �aacay;�
ADDRESS ;i�---Z g.ct!4i�./1�s1t JOB SITE APN
OWNER
i Ii1 I)l1 ", 1WV 4 it f «rte t i kn S�. �r,,�N raU(•
dt_J!®t ;.1{L. is 1.1 ! "l -c 9I Yca_ t•i1
USE OF PERMIT
CONTRACTOR / DESIGNER / ENGINEER
I Ja..3f'8i 11.4 '1�,/, �✓3�i,i a 1 � 4A6i i, a'eE 13,, .. i0 al�
T,zROO AVEN IE h FTM., S i°, L 135
„nij•1)- 1.1:4 �A,.La A,144B. PP..Am�f t4"t .14 1;i,Z+x1.1L A+K.o,:{CE I,;Mi.iA't_A
1'(X ,f11
��C1�1;�Si?f<t'l'.Alt4"•�Fi.°1' fr"�'f.i��J :fl=:
Fn�{•C A!r'.J;� 4' 2'.� Y•�..'I�' i.fhl� � `ibl�i4� �.49.�.Y� . U 9M�V�V
i.6�! y�J i?�.�.Y
(:`(t�z�nf%:'t�f1.�'ia►� t��T");
lllle9!�4U,.�i)2�f��)JI
?'.t,;d;itt
N� ,kl1X10%," AL 1`1-3.°4``.
?914;NA YN -0111
i.t JA_ i 11fJ. Ai. f f ill'
P1 0ktH1N'O 11Wx
fill# VG0_.41(P_000
1'50.tk1
fIt14i1!)(}-14,141af)
AR's i_' rt3.tx` $I.Af'.iS-1r4wtP
; ° tic f�rf3-b�
S/z SCC
RECEIPT I DATE
LESS pi& PA011) i'iri 11�1 �:�fi3 try
NIPAr
DATE FINALED I INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
al'
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
oZ(.
F.A.U.
Framing
S_
Compressor
Insulation
„12-80
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
14 -1 i - TO ki
Final
Final
R�\��-oL
POOLS - SPAS
BLOCKWALL
APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines,?:
Lt • �I�y (/j_
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
• X —� _QQ
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final 9 1 j as C�cbt
Utility Notice (Gas) V loo
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 OO
Final Ck 50 (�
Utility Notice (Perm)
CertificAte of Insulation
Your Home hag been insulated with trettainTeed Fi'liarW= Insulation pmdtrcts, wb=h are designed
for W&ft saf v s7andards sect wmwfi w s energy w*wG=1d&
Fibergl 4 is inorpmc and therefore pearuanenfly namarmbnstible, so it does not have to be Ualad
with fueaeWdam d=ecals that v iill h ly lose Ow aver time. It has not bees orated
with chemicals tiw can oarfode wiring or mal. Fiberglass will not abs nib m i sta nor wffl it
settle over limn as may other ulmdation nw0cuale
Tbu also ooMfies that GertaidVeed Fber Glass insulation has been p uresdowNy. installed xn this home
to pmavide the following then W pci6ormaam. _
Job Name: Sonriea Tma: 25953 Plan #; 4 it'hase: 3 '
Let Nw. 58 Job Address: 99-462 Calle Saafisa�La Q 'ata, CA
Cel Area: R-39 Unbmd C.arsge Ceiling: °
With 11ving Ahove .
In# or WaIIe• Ederior Walls: R-13 Unfawd
P" �ilsils: Wild Uv%gAbove
(2 layeri) CeirmS eaten'
S'nconb�ctor.. OfInsuk on Ca, Inc.
wu� A� CA "742 (M6)tn2•Wo assa70P
hK
Stgaed
E'oncli to 040. SecrewyArreasurer --or-- R .Scion Jenkins, PMi*Iit--or
Lou Merola, Director of Qperatiolas OA'%er
R- means resistanoe tb Feat flow. The higher the R .value, the gmatef the insulating pawur.
Ask ym builder for rhe :Ihct shed. on R values. Keep this eedificate wilh your, other
valued gapers. Ifyou ever sell lies home, this oestificaw should be passed on to the buyer.
I