0108-006 (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
`1$ .3 0/'3114) 1
Date ' +.OM ,'; 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: r
( ) 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 owneri 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 f 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 ���.�t r�,t� �t Policy No. fl
Q0J,r.IW..CTF4 z.?x ��es: 11'�w'. 11�'S 11<''-544063.03
(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: c• rim r. Applicant
- f r/l
Warning: Failurelto 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. ;µy
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. b.
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 l 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.
Signat u e Owner/A ent r ( g ` } :'!:~�� 1 ` /f A
^ i { ; + r .; ; Date •
BUILDING PERMIT PERMIT#
DATE VALUATION LOT �R�{,�t'�-•E TRACT
�
24197-2
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR/DESIGNER/EN (NEER
15.3,5114, "D" um, kr, um. inoo
1535 30. 17)" SrRT.fi, r, MY" 9200
ISAN 1• �I�1''iY.4AdMINO LCA . 9-2408
SAW DE1'+.1�ARDWO CA 92409
(909)381-60(Yi (:k3LA 2 120
USE OF PERMIT
�#liJ�63•J..�; ,i�,9f1'C."�' ��ar1:��,s,��a'
5111- PLAN' 2A,, $ADT2- PERMIT I)OF314CIT DIC:UJOR {31,0,C"K.
WAIAXIP iO4 SPA OR DiltNMAY APPROACH
TRACT 0011 '; TRUCT'10H 4.804.00 SF
POkCWAT40 49110 V
0ARAMVARPORT 420, go OF
=M1.rdl1XrE)D C'Mr S?Y 0011 KIR5.I6i Rd.R.FBV
1061firi.70
SLAW CHECK F 309 -f]OfE 39-31 (¢33B.Lt
�4�Xt 4Bd11!{ L''c t� €� P 3.U'i 'i3{20 a21 303 $60.00 .
R1AXRIC-A,PEF 101-000-420-00 $110.90
1'L1JWN0 :RE 101..000.4194000 5130.00
WRONOMOTIOla PE1:.RESID 101 -WI 0-241-000 $10.66
GRJ'.i31140 RE 101.000-4123-000 520.09
1WETat'k1al;'Ei! IMPACT VTZ �1�4Ql.00
:fit° t11..C"L Y i F1 iC1110`� .WD PL i.°. ,01C`IL
�t �y�e� �,r.SQ
1303 SIM -PAID � KES
$0.00
$:61,M:@Y.& Mb.1)-trg.49aa/W
0i0•3,18D
AUG - 3 2001'
i
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MuIP7 7 "'thiATE"r
1
BY f
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
I INSPECTOR
OPERATION
DATE
INSPECTOR.
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
_
% d
Underground Ducts
Forms & Footings
(
Ducts
Slab Grade
��Zy /d
��
Return Air
Steel
l
_
Combustion Air
Roof Deck
6,_6�
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
_�
Compressor _
Insulation
—Ls -U
Vents _Al
Fireplace P.L.
_
Grills _
Fireplace T.O.
Fans & Controls
Party Wall Insulation
_
Condensate Lines
Party Wall Firewall
Exterior Lath
_
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
I
I
I Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
8_l3��
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
O�
_ _
Pool Cover
Sewer Connection
l
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
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IN LATI N ERTIFICATE
c This is to certify that insulation has been installed in conformance with the current energy
regulation, California Adminl$trative Cade, Title 24, State of California, in the building located at:
Y.
T9.914 Dandelion Drive, Lot 2, Monticello -Heritage, La Qulnta, Callfornla
CEIUNGS-
TYPE: BLOW
MANUFACTURER: CERTAINTEED
THICKNESS: R-36
WALLS:
's
TYPE: 8A17•S
MANUFACTURER: CERTAINTEED
THICKNESS: R-13
c
GENE: C❑
ACTOR: CENTURY CROWELL COMMUNITIES
LICENSE # 7/
BY;
TITLE: e!�&ar S
m
i?
PARAGON SCHMID BUILDING PRODUCTS, A MASCO COMPANY
LICENSE # 632072
E
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BY:
TITLE: ADMINISTRATIVE ASSISTANT DATE: 12/12/2002
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