0109-017 (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
690645 S MC A W02
;�,,,I.
Date r� 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&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.
STATH, MIND
(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 sous 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 provisions.
Date: ?^� �'^f Applicant-
7
pplicant F""`
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, indemnity
& 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.
Signature (Owner/Agent) - j l! Date '
....... ....:.
BUILDING PERMIT PERMIT#
DATE t VALUATION LOT TRACT
;: / 19 , i751 {S '14 29R:58.1
JOB SITE �'"""-
APN
ADDRESS.
5 IL 'al Fd. A d.)E�
S'P d1��i3-QEd 3t
OWNER
CONTRACTOR/DESIGNER/EN INEER
"r HOWS L110 .
RXr ufmrmwmINN
�,f>t.�j ''► . CA 92253
!'HOEM AZ 85034
(602).257-1656 CBVi 4990
USE OF PERMIT
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PCaOWISi�., OR. DPP' W. AY APPROACH
T41t",f Ct711OI'RUC— IO)s m91,00 SF
ir0'R.OWPA°!10 1569.00 SF
C4Ame-VlCA.RPORT 138.100 air
nam.Anw Con oir coxym i"clion'
1,01370M
PIRWTI WE HUMM,t R
t lvi 31'x@ �` '1C+11411 . M.000`418.000
VLkA CHHVK FEZ I01-000.-439-318 $a'rz.d.6
MEQ CHANICA1, V F 9 103-000-421-000 $105.00
MEMUCAI, M. - $204.9.31
PR met,; 4C5 ne 101.000,41 9-000 $2301,00
S I RONO MOTON FEE REBID 101-000-2/41-000 5:9.14
ORADIWO P1 '101=1700-423-00!0 S"A
1 'EVEL QPM XIMPACT VZZ
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11103 M-PAORMW
MOO
SEP.. 0 6 2001 I 1ITMOT M'S IDU E. NOW
CITY OF LA QUINTA
FINANCE AEPT._�
RECEIPT
DATEi / /
BY
DATE FIN LED
INSPE
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs �v` Q
Underground Ducts
Forms & Footings(�_
(
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck_
O.K. to Wrap G
A
Exhaust Fans
F.A.U.
Framing
_
��/_U
Compressor
Insulation3
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
`Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
�� — U
_
`
Final.
Final
POOLS - SPAS
BLOCKWALL APPROVALS
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 f
�
Heater Final
Water Piping!/
_�
Plumbing Final
Plumbing Top Out
�K
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
7� 0
/
Pool Cover
Sewer Connechon�
—
(r
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
l'j✓
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Az % •f�/
�—
Low
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
'
Utility Notice (Perm)
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:
50-065 VIA ALDEA, LOT 74, LA QUINTA, California j
CEILINGS:
TYPE: BATTS MAN UFACTURER:,Certainteed Thickness: R-38,
WALLS:
TYPE: BATTS MANUFACTURER: Certainteed Thickness: -R-21
/�
GENE L ONT / CT R RJ T H S LICENSE # b D l
B TITLE-���I���) i
ON SCHMID BUILDING PRODUCTS, A MASCO COMPANY LICENSE #632072
Y. e TITLE: ADMINISTRATIVE ASSISTANT DATE: 11/13/2003
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