0108-013 (SFD)LICENSED CONTRACTOR DECLARATION
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
Date mss/ f 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, A 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. ,
MUM "ME dx�`�. 4 Edi�C�S��Iit fsl`fD3
(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
DateApplicant—_,Y. 3 * `19 1 L f t, . .A
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, indemnity .
& 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 ofsuch
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 enterupon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) h y �� t �� -- -� %+ Date Y �✓
N L'
BUILDING PERMIT PERMIT#
DATE I VALUATION LOT TRACT
JOB SITE !
APN
ADDRESS �l� Ct �y try y { p p.y�/��lY �p� q/
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404-01 d+TtRO.67 f2;
OWNER
CONTRACTOR / DESIGNER / EN &NEER
clwfUpty'"..)':ovau, COMMM frumC°k:1
T't�13� 1". t0 t.;i9lyor b4 13td1 TGE
1535 11.30, 9DN 3MU!" ,15M B oo
1535 so, 1)0 7.i m. IBM 4200
' RAN BXa4 MXWO C. k 92408
SAN Zr.:1�iMDX.NO e,.,A- 924 08
(909)381.600'l CBL,# 2120
USE PERMIT
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TRACT CONSTRUCTION
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0ARAWCARPORT 604.00 V
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14W43.00
PRMT. 11 SUMMARY
CO1•!OTRUC I(YA 101.000 -4f118 -GW MUD
FLOW r"111< "N" PT-zr lot -000-4391.318 $165.28
MP,C)MNlCAL FEE 101-000-421-000 $66,50
%f.,.�,�',It*�;IA.L•f�1� °4424-(�)0���t►-�i0t3 stQ4.5Ff
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PI.,9;1MOTHO PHE 101.000`449.000 $1�42,f3t1
3=0140 FdfO £`itil➢ ME - RESID, 101-O O-24 ).-000 �1d:3Q
OS,,gesyf�$.fOi��d�.ty��7Fy')2 101 4000423-000 00
pp$/�'d
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DEV 710PEA 2iV.'.b'�iGY lrEY,
j 1� 1 i 4'A►I, t" 3 . 9 15 G1Y� d Ae1� 'C.S+,AI i`7ll l"`FC.
$3,2,19.66
LESS PAR -PAID
$0.00
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RECEIPT
DATE
BY /
DATE FINALED
INSPECTOR
I!
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
Set Backs�r
APPROVALS
MECHANICAL APPROVALS
Underground Ducts
Forms & Footings
_
0
Ducts
Slab Grade
/3�/(,z
ReturnAir
Steel
_ _
Combustion Air
Roof Deck
�d/3��
Exhaust Fans
O.K. to WrapZ
Framing
Insulation=�_U
Fireplace P.L.
l ' Q j
� � 1i � �(
(
F.A.U.
Compressor
Vents
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath l �_
Drywall - Int. Lath _ 2
Final
_
Final 3 �;
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
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Plumbing Final
_ _
Water Piping�� ��
Plumbing Top Out
t
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
_
Appliances
Final
COMMENTS: /.313
Final
Utility Notice (Gas)�D
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)
,10%T7L2013 00:59 RAT 16008/019
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6
INSULATION CERTIFlCe47E"' '
k
This is to certihj that insulation has been installed in conformance with the current ene-gy
r
regulation, California Administrative Code, Title 24. State of California, in the building located at:
79.885 William'Stone Way, Lot 9, Monticello -Heritage, LaQuint:a, California.
r CEILINGS:
TYPE: BLOWMANUFACTURER Certainteed Thickness: F2-38
WALLS: A
TYPE: SATTS MANUFACTURER: Certainteed -'Thickness: R-13
GENERACOWNTACTOR, CENTURY CROWELL COMMUNITITES LICENSE
BY: TITLE: 4}&,; S
PARAGON SCHMIO BUILDING PRODUCTS, A MASCO COMPANY LICENSE #632072 "
�.. TITLE: ADMINISTRATIVE ASSISTANT DATE: 12/12/2002
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