0108-035 (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
Dated ""' �� 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 t4C `y t Yspt y y� yea Policy No. �3J p 1gp�p laI'
00y.mal l /.:.,A n1,%J.RSi
(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�,.�. f
eac ( 1 .1- r.rr
Date: Applicant �. 1093 �¢ '< < 4n
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
oany permit issued as a result of this applicaton agrees to, & shall, indemnify j'
& hold harmless the City of La Quinta, its officers, agents and employees.! I �:
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 cf such I 1
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);� +Y1,' Datet + a
BUILDING PERMIT PERMIT#
DATE VALUATION LOT {fib TRACT
24197-2
JOB SITE 1
APN
ADDRESS
-•?M `t X0rSX?,1Y AVEMM
604• 'rk- 006
OWNER
CONTRACTOR/ DESIGNER/ EN (NEER
en l i!:. PLY MOW& T CC3'h .UMWIS
CmI°C RY C"PFtCi'WT ,C.1, CCJ.f1tGM1'I.3,t�f1I'TE S
15uR:1 So: -v- ulpy-ur, zi'n" noo
7 m-15 so, -+ asr"m 1124.1
B.1.04 BF.RN,F1,1 1.140 CA 92408WMXNA.RD.D
O CA 92,4409
(t�L�q}:%m r47>0."n a"xllf 2120
USE OF PERMIT
ON OU FAMILY DWEAM0
SP'.)� MAN 3.A.R-ey; L I-31. 9pLi'P..MIT T101 -N NOT aINC:i.4,iIC3Egf.,OCK
1:F:taWSf'i"4Old'FOR 1SaSU ANICV OF SAJAk h; PIAW kvP.
TRAMCONSTRUCTION ni`RUC:?•1C'rN 19.00b Sr
PORCHIPA1110 SF
C4AIL40AWARPORT 625100 OF
X1!.5 VA r1JBi�%� CONT OF °u,•Od7L7w.E.R 1 J.�� 14-
M,J'.R0ao
�n �l�y.�
.S: LL.a`Yit V E kli,7:lAblWS
COrNSTRtBC'B ION TTR 141.900.418-000 $1415,00
PLAN CHECK ME 101-000-439-318 $160:11
MIMHA1~ WAL ME 101-00()-421,_000 $60.00
9LIZTRICAaL MR. 101-000-421.0,000 $138.53
PLUM.90110 FEE 101 -000-419-000 $124.00
T WOW0 JV.O '100 VER •. MID 101-000.241--000 $13.24
1{�1 �t1f} �t10'"9 920,00,
T+�Fiip�y
*MIADIN0
g pp�r�qqqq *
lVC1110M AND PLAt4'C5M(.X
' X51.5 r .k'"RRA. AID M3
$3#177.93
$0100
AUG -3 2001 _
CAN Lai QL'I,1TA
FilW,FVU DEPT
RECEIPT DATE BY " . DT I ALED 2 INSPECTOR
rfi
J'
Kt;gi
INSPECTION RECORD
D
OPERATION DATE I INSPECTOR OPERATION I DATE I INSPECTOR
BUILDING APPROVALS. MECHANICAL APPROVALS
Set Backs _ Underground Ducts
Forms& Footings0jL2=_ ��p� _ Ducts T��7
Slab Grade 2 Return Air
Steel _ Combustion Air
Roof Deck Q (� ` _ Exhaust Fans _
O.K. to Wrap _ F.A.U.
Framing • . _ , �Compressor
Insulation _ Vents
j
Fireplace P.L. Grills
Fireplace T.O. Fans 8 Controls
Party Wall Insulation_ Condensate Lines
Party Wall Firewall _
Exterior Lath
Drywall - Int. Lath
Final
Final POOLS—SPAS
BLOCKWALL APPROVALS Steel
Set Backs Electric Bond
Footings 3 — Z Main Drain
Bond Beam ��� _ Z� ' Approval to Cover .
Equipment Location
Underground Electric
Underground Plbg. Test
Final /—Z Gas Piping
PLUMBING APPROVALS Gas Test
Electric Final
'Waste Lines �/Z f� Heater Final
Water Piping (� _,��cyJ Plumbing Final
Plumbing Top Out Equipment Enclosure
Shower Pans O.K. for Finish Plaster
• Sewer Lateral �,Z — �Q _ p� Pool Cover
Sewer Connection Encapsulation
Gas Piping
Gas Test !99—O.Z
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas) 2 :—
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
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:
44-788 Liberty Avenue, Lot 31, 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 COMMUNITITES LICENSE #
- BY:
TITL
PARAGON SCHMID BUILDING PRODUCTS, A MASCO COMPANY LICENSE # 632072
' B TITLE: ADMINISTRATIVE ASSISTANT DATE: 12/12/2002