0106-236 (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 �y"> Signature of ContractorF{�
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.
G'`OJ!.AA914 EMAX rNS,
(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 provisions.
Date: 7 f' �� `�� Applicant �'"r), °�^-5:77— ,4,
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in .Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject, to 'the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days. from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
i
Signature (Owner/Agent)?- Date��F✓
PERMIT PERMIT#
/BUILDING
DATE VALUATION LOT {j';�,j,�g.."A TRACT
R1
JOB SITE
APN
ADDRESS '76422C]3LE AlN RMiqyAc
769-0214N)
OWNER
CONTRACTOR / DESIGNER / ENGINEER
SA$d UP!'AWN 0 CA k92408
'hSAN MRNAIRDT00 C A 924 08
MIA 2120
USE OF PERMIT
KN4MR, & A. 0 8 1) C " I AT FP,
GUI P.PUR,yDINEXIN
3990 "INMT"L?k;.I Y !'i.,.&CT+.
M? • Wil' 29 Pf..AMN h3 ti PE'RMT fBi7.ti;S 140T iNCLUf22 ]<ILOCK'6+td LI,
POO -14 OR, DRAIMAY,6PPROACK 75%PLANCHECK WE O:fi}' MU',:TIPLF
I.SSU,01=fJT+ gAME PLAN TYPE
C'001YOM CONSTRUCTION ZJ107100 OF
IPF;'R.f*XPA A,'I' 0 206.00 sp
0ARAOTUCA PORT 404,00 OF
. I) Ct1;, T OF (. O.NUMUCTio n
1'364567 0
g:4��.:i5"TINt4.ii'
tit?NSTAUCTM JIBE 103.000.418.000 $009,04
FLAN 04Mr, M 101o=-439-3'18
MECK&NICAC FEE '101 -000-4121-000 X43„SO
i'I.FU a&M3C —1017.0 )0Q�
."?'FROW NOTIOW FEE P lel E 11) 101-000-24Y-000 17.66 ,
ORAD[NO RIP, , 1.01>000-423.000 $20.00
IN FRASMUC"I'iJRlv;`, P'= 221.000-443-.342 ),m oo
i
y
1
SIM-TOTAT CO .�i��a�F
• CITY OFA
FINANCE DEPT
v:y
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
PATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms 6 Footings/Jl=
Slab Grade
Steel
Roof Deck
O.K. to Wrap
Framing
Insulation
_ _ _
O
/
(Z8- O�
` /_Q� ����
�/ _ G� 6'
_ _ U�
1 Z�c�/D_l, t>l'
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans.
F.A.U.
Compressor
Vents
_
a� _
�—
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
3 /3— �.S
:Final
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
�% 32
He ter Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral /
Sewer Connection
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
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) :2-,/ 2_d `
FEB -18-2002 14:14 WESTERN INSULATION 909 686 8786 P.13i24
WESTERM IN ULATION ` L o o s
4211 Latham Street, Feverffide, California 92501
TeL (909) 686-8760 Fax (909) 666-8786
INSMATICN 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:—DU NAC FAIRWAYS TR#29586 PHASE 4
GLOT #: 29
SITE ADDRES9 78-322 CALLE LAS RAMBLAS, LA QUINTA, CA
EXTERIOR WALLS:
MANUFACTURER: JOHNS MANVILLE THICKNESS: 3 5/8 " R -VALUE: R-13
EILINCS: BATTS BLOW
MANUFACTURER: GREENFIBER THICKNESS: 8.1 u R -VALUE: R-30
CEILINGS- BATTS BLOW
MANUFACTURER: IOHNSMANVILLE THICKNESS; 11 " R -VALUE: R-30
GENERAL CONTRACTOR: CENTURY HOMES
BY:
TITLE:
DATE:
1 S1y_ULATION CQNT9ACT R: WESTERN INSULATION, L.P,
LICENSE NUMBER: 794484
BY: x '�
TITLE: PRODUCTION MANAGER
DATE: FEBRUARY 18, 2002