0108-019 (SFD)LICENSED CONTRACTOR DECLARATION
I�h:reby 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 # Lia Class Exp. Date
Date `" Signature of Contractor '' )✓
f..., f r
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).
l ) I, as ownerof the property, aM e50iu9iV6ly COhtr2Ctirlg 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 herebyaffirm 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 Policy No.
OOill"EN EAOLE TH11. NW -54406M
(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, l shall forthwith comply with those provisions.
Date:* 5"i`'" 1. z Applicant `.P y �, f 1'.7 -7
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
ees.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. i
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 of such
permit, or cessation'of work for 180 days will subject permit to cancellation.
I certify 6af 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. ,
Signature (Owner/Agent) �'� fir' =) t Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
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OWNER
CONTRACTOR / DESIGNER / EN (NEER
r-HIIZY MiWEMLCOTs41�81
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R 535 A0. *D" UpPUVI 1Ay200
1535 U0. ID"MgEr, 06R,0�30?i�3:
IBJ' Ti��.Tl.�`WAIUDWO CA 9240:8
SAW B1+:>~,�.MTa)i1 0 a°:` -.A 92405
(9095)381-6007 CB0 1611120
USE OF PERMIT
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625,00 OF
COST, Ole COMMUCT1 )N
Jlwi2„910.20
C-ON3, TT#.',SMON PIKE 101.000.416.000 SW5100
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PLAN CHWE" FLfz 104-000-439•128 $160.11
ME D.0 ?t'a:TC AL YNED g i14tlilL ? 1 � t3S1i3 56�>!!�
T,ii,.FIC,:'Wf, A , PEE 101-t300.42:0-000 $134.53
T•iTd3YM2NKG FEE 101.000-419.000 $124101
S` KONDMOTION PEP, ,' • F—rAWD i 01 CIf1(1-?el1 «i3tyf, $13.34
CRADING X 't 101.-0004?,3-W0 $20.00
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$3,177.o
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CITY UE LA WNTA
FNAKE DEPT
RECEIPT
DATE
BY/
DATE FINALED
INSPECTOR
rT INSPECTION RECORD
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
Set Backs
Forms & Footings
_
71
Slab Grade
Main Drain
Steel
Roof Deck
O.K. to Wrap
_
/s!
Framing
Insulation
Equipment Location
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Underground Plbg. Test
Party Wall Firewall
Exterior Lath (�7e5l
Drywall - Int. Lath
��_
OPERATION DATE INSPECTOR
MECHANICAL APPROVALS
Underground Ducts _
Ducts
Return Air q�/' %
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans & Controls
Final
_
3 Z /—S
BLOCKWALL APPROVALS
Final 3/ —-
POOLS -SPAS
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
Water Piping
_
Heater Final
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
Utility Notice (Gas) I J p// - ,-- y U
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Tema. Use of Power
Final S
Utility Notice (Perm) �_s_
COMMENTS: 1013 2 -s -o2 -
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INSULATION CERTIFICATE
This is to certify that insulation has been Installed in conformance with the current energy ' -
regulation,'Calitbmie AdministratNe Code, Title 24, State of Califomiar in.the building located at:
79-892 William Stone Way, Lot 15, Monticello-Heritage, La Qulnta, Callfomia
CEILINGS: -
TYPE: BLOW - -MANUFACTURER: Certainteed ,,Thickness: 1�-38 a.
WALLS: -
TYPE: BATTS MANUFACTURER: Certainteed, Thickness: R-13
GENERAL CO RACTOR: CENTURY CROWELL COMMUNITITES ! LICENSER , r
' BY: y" '
TITLE,
PARAGON SCHMID BUILDING PRODUCTS, A MASCO COMPANY LICENSE # 632072: ,
� r e
B = TITLE: ADMINISTRATIVE ASSISTANT DATE: 12/12/2002 1' r
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