0109-018 (SFD)ct LICENSED CONTRACTOR /DECLARATION
.•Lh.reby'affirm under penalty of: perjury'-that,ITam licensed under provisions of
G `Bpter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is inT,full force and effect.
License # Lic. Class Exp. Date'
Dates 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 SectionB&P.C. for this reason'
Date Signature of Owner
WORKER'S COMPENSATION DECLARATIONi
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:
Carver Policy No.
STATE MOD
(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 pvisions.
Date: Applicant %/ °4. �� •� rr._
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 purposes.
'Y.
Signature (Owner/Agent), k'-'% '� ` Date
BUILDING PERMIT PERMIT#
DATE ,,�� J� !� VALUATION LOT TRACT
`AS
JOB SITE
APN
ADDRESS
UP= VIA MJ)il:A
772-tlW-fit
OWNER
CONTRACTOR/DESIGNER/ENGINEER
W'i'HUMUS UIC
RJT A+MffrMF M,C5.
OBOX 810
1425Th UNAWNTYD
LA QUMA CA, S12214
rWCJM071 AZ SQU
(6432)25' -1656 C $ 4 ti
EE
USE PERMIT
yOyFy 7R,MIIT+ rp.
$FA :1.443' ii PLAN P313. PEM 1711OWS WOT 1NC7..i OF, BLC)t;r'9trAiLLS,
PWLTASPIA 0131'Y]aIVEWA.YAPi'g3.C:ACH
TRACT CONOT1t.13C`TION %2M100 vp
P RCHIPA' IO, -960.00 NIP
Q.A0_FJCARN)RT sy
FISM" ET MIST OF co-WRITMC'A'iom
�i3E� .Cid
`CeAii3l ttT>v i'9C13�F FIM 101"000-410-000 S99101fl .
FLAN CHECK FTE. 026.07
RA1';CHANiUhl FEE moo
Fl1.,1f.G2'1ti'.liIA.11 FFIx: l i"4 a'.000420-000 010.30
PLUMI 3WO PUS 101.000.419.000 13140.0
M.0140 VICITION ITE - IMSID 1 X91 ••(10 -241 �-($bD 2�i.Q9
GROIXel'1 FRE 101 _000.42:3-000 2G:G'zi
T,DEVVEL' PLU IMPACT FES
ART 1N PUDLIC PLACES - RESIE 270 -000 -445 -NO
SUB-I'MAT, CON"I€'1i2i3C;°'t.TO AAlrD Bax..AR 0.7,190C
$3,894.69
%JEW FRE -PAID I?h
$0.00
D J
L M -M -C M8 DUE MOW
SEP 0 6.2001
CITY OF LA QUINTA
y • FINANCE DEPT.. :�
'
RECEIPT DATE % ,� . BY FIN ED I
.a?
PECTOR
a 111.
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs • 3- Cr
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel .
Combustion Air
_
Roof Deck
Exhaust Fans
O.K. to Wrap�/_
F.A.U.
Framing
�� u C,i %
Compressor
Insulation
/,�• 27- ��
Vents
%
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
_
�_ 0
Drywall - Int. Lath
Final
Final
_� _ __ _
POOLS - SPAS
BLOCKWAL,L. A?PROVAL.
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
��� .-p �/
Heater Final
Water Piping
_
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
/ ' /1-e w.�(,
G 'O t!
Utility Notice (Gas)
✓ -- - — — —
ELECTRICAL APPROVAL
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures r/
Main Service
Sub Panels
Exterior
Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
f//U/U/f//f/' 10
J
INSULATION CERTIFICATE
This is to certify that insulation has, been installed in conformance with, the current energy
e
regulation, California Administrative Code; Title 24; State of .California, in the building Iodated at:
0 50-025 VIA ALDEA; LOT 73XA QUINTA,CALIFORNIA
CEILINGS::
9 TYPE: BATTS,.. MANUFACTURER: CERTAINTEED THICKNESS.: R-38
WALLS:
TYPE : BATTS MAN UFACTURER:.CERTAINTEED THICKNESS: R-21
i
//
GEN L CO T� CT : RJT S LICENSE #U9®
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TITLE:�F(7 tpra)owT
ON SCHMID BUILDING PRODUCTS, A MASCO COMPANY LICENSE # 632072
i
TITLE: ADMINISTRATIVE ASSISTANT DATE: -11/.13/2003