0108-032 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with S4i;tion 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 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.
GOLDEN ]MIA, N'A
(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. 1
.a �:,
Date: el:I /'� i Applicant M .k 1"r='r.a 4 t �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 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 th;s 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. ,
Signature (Owner/Agent) L 1. .c ' t� .f Date
BUILDING PERMIT* PERMT#
TRACT
DATE i VALUATION LOT TRACT
?S 24197-2
JOB SITE
APN
ADDRESS
44-1W4 7co.I.1�I�. R TTY l�.�l�:.clib �R•�-
OWNER
CONTRACTOR DESIGNER INEERM•/��
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MUCTRY;` AL, NEE 101-000.4-20-000 $144.59
01-+100.419.000 $142.09
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flNnMVEP`(.
RECEIPT ) ;
DATE
J %
DATE FINALED
INSPECTOR
BY
INSPECTIOU RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
Set Backs
Forms & Footings `� D
Slab Grade g ��_ �/ _
Steel _ _ _
Roof Deck Q �6 _
O. K. to Wrap
Framing f=� �.y� _
�� ���.p�
Fireplace
Fireplace P.L. _
Fireplace T.O.
MECHANICAL APPROVALS
Underground Ducts
Ducts )
Retum Air / - -
Combustion Air
Exhaust Fans
F.A.U.
CompressorInsu
Vents —
Grills
Fans & Controls
Party Wall Insulation—e�%J.�-�
Condensate Lines
Party Wall Firewall '
Exterior Lath
Drywall -Int. Lath
%Z=
Final
2
Final
POOLS - SPAS
BLOCKWALL
APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location '
Fj
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
}/��
Heater Final
Plumbing Final
Water Piping `� - �' f
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Pool Cover
Sewer Lateral
5
Sewer Connection_
Encapsulation
Gas Piping
Gas Test
/ _ -0 2 -
Appliances Appliances
Final
COMMENTS:
-
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring _ 2 -% - J —77
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:
44-704 Liberty Avenue, Lot 28, Monticello -Heritage, La Quinta, California
CEILINGS:
TYPE: BLOW MANUFACTURER: CERTAINTEED THICKNESS: R-38
WALLS:
TYPE: BATTS MANUFACTURER: CERTAINTEED THICKNESS: R-13
GENERAL CONTRACTOR: CENTURY CROWELL COMMUNITIES LICENSE #
BY:
TITLE:
PARAGON SCHMID BUILDING PRODUCTS, A MASCO COMPANY LICENSE # 632072
B TITLE: ADMINISTRATIVE ASSISTANT DATE: 12/12/2002