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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
743$67 13 7 2r+ 1/2(
t,Date !f, -� ' -"Signature of Contractor S C
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 eSTATE FUND Policy No. IS09393.99
(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
work fs"compensation laws of California, and agree that if I should become"
subject to the workers' compensation provisions of,Section 3700 of the Labor
Cdde, I shall forthwith comply with thoseprovisionA G�..-
VlKate: `%• Applicant—
Warning:
pplicant 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
t e above-mentioned property for inspection purposes.
Signature (Owner/Agent) e` `,- Dateu
BUILDING PERMIT PERMIT#
DATEf VALUATION LOT TRACT
4'12 s1� 51.00:3.30 17
25691
JOB SIT
ADDRESS79^ 71i 7Ci,1 N13.F..L.IG1N DRT
APN
dt?4 072 fl Ya
OWNER
CONTRACTOR/DESIGNER/EN (NEER
ALM DM D LLC
WORM DEVEL.0PWWT, BIC
74.333 i3KHWAY 111 If 103
74.333HWY 111911; 103
F?.fl,LM DESERT c ,.k 92260
PALM DESER T
CA
92260
`760)306-2955
CRL4
5028
USE OF PERMIT
21T►7(1L'Ia: i+AAd LY'3aWALING
SYD-LOT 171 PLAN 2APE MIT DOES NOT 17dCLUDE?? BLOCK►7+T.AL.LS OR
POOL,
TRACT CONOTRUCTION 2,511.00 SP
.
PORCHAIATIO 68.00 vp
0ARAWC:AP,PORT (Si) 1%641.60
1r'n7,>.1!f.A!'km COST Ora Ci3:i`1YrRuC'.1ail7n
1SU,1593.30
p0tm •C b"Ti'k", SUAA tARY
CONSTRUCTIO14 FEZ 102.000.418n000 5819.00
PLAN CHECK PEF;. 101-000-439.318 $171.83
M9CtW11CAL M- E 101-000-121-000 $98.50
-
ELECTRICAL PEE 101-000-420-000 $150.31
.
PLUMBING FEE, 101-000.419.000 SI61,25-
STRONG MOTION PEE -12.E-91Ia 101-000-241-000 $15.09
t
GRADIWO IEE 101.000.423.000 $20.00
DEVWDPER.IMPAC`P F?,' $1,907.081
s �Y
- t.3;..,.
SUB -TOTAL COHMUMIOA1 AND 1''i,AIR CR CK
$30342.00
],.1795 PRE -PAID FEES
$0,00
TOTAL 119RMf YMN DUE NOW
V'4,342.00
s,
RECEIPT
DATE
OTI
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
Set Backs
PLUMBING
Forms & Footings
,•iZ _ L�
Slab Grade
g sZ
Steel
Water Piping
Roof Deck
Plumbing Final
O.KtoWraD
7•17•On r.
OPERATION DATE INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Fireplace P.L. Grills
Fireplace T.O. Fans & Controls
Party Wall Insulation Condensate Lines
Party Wall Firewall
Exterior Lath
Drvwall - Int. Lath 49� cT
Final Itv, lo' O�_Q
BLOCKWALL APPROVALS
Set Backs
Footings
Bond Beam
Final
Steel
Electric Bond
Main Drain
ADDroval to Cover
POOLS - SPAS
COMMENTS:
Final (A,-"
Utility Notice (Gas) I o1io
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temo. Use of Power
Final
Utility Notice
Underground P14, Test
Final
Gas Piping
PLUMBING
APPROVALS
Gas Test
Electric Final
Waste Lines
S -CI -tQQi
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
4 14f ,CD
COMMENTS:
Final (A,-"
Utility Notice (Gas) I o1io
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temo. Use of Power
Final
Utility Notice
Certificate of Occupancy
City of La Quinta
Building and Safety Department
This Certificate issued pursuant to the requirements of Section 109 of the Uniform Building Code,
certifying that, at the time of issuance, this structure was in compliance with the various ordinances
of the City regulating building construction or use. For the following.-
BUILDING
ollowing.
BUILDING ADDRESS:
Use Classification:
Occupancy Group:
SFD
79-578 DANDELION DRIVE
R-3 Type of Construction
Owner of Building: JIM DAN D LLC
Jb 4-1
Building Official
vni
Bldg. Permit No.: 0003-278
Land Use Zone: RL
Address: 74-333 Highway 111 St. 103
City: Palm Desert, CA 92260
By: Greg Fox
Date: 10-10-2000.
POST IN A CONSPICUOUS PLACE
SEP -20-2000 14:16 WESTERN INSULATION 909 686 8786 P.10i12
VM010E N INSULATION� INC.
4211 Latham Street, Riverside, Ca dbraia 92601
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:WILD OWER - 25681 PHASED
LOT # ("I7
SITE ADDRESS: S DANDELION DRIVE, LA QUINTA, CA
EXTERIOR WALLS:
MANUFACTURER: JOHNS MANVILLE THICKNESS: 3 518 " R -VALUE: R-13
COUNGS: ATT BLOW
MANUFACTURER: GREENSTONE THICKNESS: 10.3" R -VALUE: R-38
CEILINGS: BATTS BLOW
MANUFACTURER: JOHNS MANVILLE THIC ESS: 13" R -VALUE: R-38
j GENERAL CONTRACTOR: WORLD DEVELOPMENT
(, LICENSE NUMBER.
BY:
TITLE:
DATE:
INSULATION CONTRACTOR: WESTERN INSULATION, INC.
LICENSE NUMBER: 4812
BY:
TITLE: OFFICE MANAGE
DATE SEPTEMBER 20, 2000