0101-033 (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
Date Signature of Contractor
OWNER -BUILDER
I hereby affirm under penalty of perjury t at I am exempt from the Contractor's
License Law for the following reason
( ) I, as owner of the property, dor 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). to
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the s'project (Sec. 7044, Business & Professionals
Code). - "
( ) I am exempt under Section} tO 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 wokers' 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.
-- 5T AIIIE IF; UN D 4.109x93.99
(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,shou Id become
subject to the workers' compensation provisions of Section3700 of'the Labor
Code, I shall forthwith comply with those•prov Bions'. 'J
Date: Applicant 1// o 7 — ''r -�
Warning: Failure to secure Wo ke'r5' 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 compete tion, damages as provided for in Section 3706
of the Labor Code, inte e"" nd 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•taws relating to the building
construction, and hereby authorize representatives orfJhi fCI y, to enter upon
the above-mentioned property
�for inspection purposes.
Signature C (Owner/Agent)`----�' �Date w,..
BUILDING PERMIT PERMIT# /� /�
/V�(�(`/ ,'���
DATE VALUATION LOT ()3()d_SIaeP TRACT
7 796AZ1
JOB SITE
ADDRESS
APN
7"60LADERZA
604-071-00
OWNER
CONTRACTOR/ DESIGNER/ EN INEER
1) 3d RMIMP8It1C
WOPJ.-.,33 D1?V ,0PfMMTf, WC
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111 69T 3.03
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Rf CA 60
(760)56,R,n,55 CIBLO 41028
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USE OF PERMIT
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33,YD- LOT 7, PLAN 4A, SM - MKIWI t• tKUS NIOT INCLUDE 3'3lzw=
W.n.I M FOOL, OR, D1U`t'I?_WAY 1VP?P0ACH.
"4'RALCT CON:%TRUC TION 4,510.00 3I+
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EST,1il+1..N.irD C OFT or C4.3h1'S'I31UCTIM4
149,716,20
CONTI.1 U C TION FEE 103-000-418-000 $814,10
PLAN CHECX ITS $69A.14
&RCHA'DiICAI.vFEE 101.000-•1.21.000 MIR
F.'L, X.'T iSC'A1, F.",t 101-000-420-000 $134. W?
4,$0
1 I.UNINW-4 FEE 101.000 41 n-OOC3 $174,$0
S PR!LYJgQ MOTId3;f4 VFW-, - r.MIL) 101--000-241-000 $14.97
s:113 i 1 C►1Yr F 101-000-4,13-000
1.1&V U,t M 61M:I;',+�§.0 I' "1z P,9II7,00
UMIS 47R&PAD 1''19I1�",'1.
$0.00
TODAL 117MISTU147F.S 009 NOW
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13 .5 117 'A t
RECEIPT
DATE P� `
BY`e �f�
DATE FINALED
INSPECTOR
I ! ^t E
(S�Mr.� /R'
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
Set Backs
APPROVALS
�' /Q �>�
MECHANICAL APPROVALS
Underground Ducts
Forms & Footings
Slab Grade
Steel
Roof Deck
�// y
Z`" l CQF
.—Gbf\
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans & Controls
O.K. to Wrap 2�'2�
Framing 3 (g
Insulation ?S(8
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
3 Of
_
Final
1
PO LSt/-- SPAS
Final
BLOCKWALL
Zd /
A� �'ROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground PIN. 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
Sewer Lateral
Sewer Connection
Gas Piping
Gas Test
Appliances
�'
�i
t
O.K. for Finish Plaster
Pool Cover
Encapsulation
Final
COMMENTS:
Final q
Utility Notice (Gas)
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
Final
Utility Notice (Perm)
JUL—dS-210bl 15:1T WESTERN INSULATION 909 686 8786 P.03i11
WESTERN INSULATION, L.P.
4211 Letham Strect, Riverside, Callfomie 92501
Tel. (909) 686-8760 Fax (909) 686-8786
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:
TRACT / PHASE: DESERT FLOWER 1129624
LOT#: 2
SITE ADDRESS: 79060 LADERA DR. LA QUINTA, CA
EXTERIOR WALE
MANUFACTURER: JOHNS MANVILLE THICKNESS: 3 5/8 " Ft -VALUE: R-13
CEILINGS:
MANUFACTURER: GREENSTONE
CEILINGS: BATT
MANUFACTURER: JOHNS MANVILLE
BATTS
BLO W
THICKNESS: 10.3 " R -VALUE: R-38
BLOW
THICKNESS: 13 " R -VALUE: R-38
GENERAL CONTRACTOR: WORLD DEVELOPMENT, INC.
BY:
TITLE:
DATE:
INSULATION CONTRACT R: WESTERN INSULATION, L.P.
LICENSE NUMBER: 794484
BY: _..
TITLE: PR TION MANAGER
DATE JULV 25, 2001