9908-073 (SFD)M
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
i aktli 2130.91
L.Dt 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
SeEc lion 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.
(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.�ection 3700 of the Labor
Code, I sgall forthwith comply with those provisions~'"?
Date; Applicant
,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.
nature (Owner/Agent)- l'�"" Date
PERMIT#
BUILDING PERMIT
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DATE oTRACT
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SITE
ADDRESS 7al�`�c0 �;5&,S�,W PALL tlK7.± Y
APN ��.9:� 79Q_:.5��¢.�
OWNER S
CONTRACTOR/DESIGNER/ENGINEER
'13-120 CALL63 13STPWO, 9104
1&120 CIALLE 9-1.04
1.A,Q1Jt;vfA CA 92253
CA
/LAtI�C�J%CKrA
Vy9�O22;!13 awl
USE OF PERMIT
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RECEIPT
DATE
BY ' ' j f
DATE FINALED
INSPECTOR
INSPECTION. RECORD
OPERATION
DATE I
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings _
Slab Grade (
Ducts
Return Air
Steel
Combustion Air
Roof Deck p .- —VF
Exhaust Fans
O.K. to Wrap — f7 S
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall insulation
Condensate Lines
Party Wall Firewall
Exterior Lath to
Drywall - Int. Lath
coo/ Z Zo
Final
BLOCKVVALL /APPROVALS
Final
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
}
Equipment Location
Underground Electric
Underground Plbg. Test
1
'
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection p—� _
Encapsulation
Gas Piping
Gas Test
Appliances
Final
k: •`
COMMENTS:
Final
Utility Notice (Gas) l
ELECTRICAL AP ROVALS
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)
�4
DEC -08-1999 1127 WESTERN INSULATION 909 686 8786 P.09i10
WESTERN INSULATION, INC.
4911 Latham 8tmet, Rivemida, Cath mk 9woi
(909) 666.8760
1909) 686.8786 Fax
I_NS_IJI..ATION 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: SEASON VILLA -PHASE III TRACT #:28019
LOT#: 47
SITE ADDRESS: 78-240 DESERT FALL WAY, LA QUINTA, CA.
EXTERIOR WALLS:
MANUFACTURER: JOHNS -MANVILLE THICKNESS: 3 5/8
CEILINGS : BATTS BLOW
MANUFACTURER: JOHNS -MANVILLE THICKNESS: 13
CEILINGS s BATTS BLQ
a
MANUFACTURER: GREENSTONE THICKNESS: 10.3"
GENERAL CONIRACTOR:
LICENSE NUMBER:
BY:
TITLE: �ye�
9
DATE• /2 -6.9. c�-
WORLD DEVELOPMENT
R -VALUE: R-13
R VALUE: R-38
R -VALUE: R-38
INSULATION CO_ NTRACTOR: WESTERN INSULATION, INC.
LICENSE NU ER: 481278
BY: -
TITLE: ProductOpNaner-___n
DATE: DECEMBER 8, 1999
11
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