0108-012 (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 # 6c. Class Exp. Date
tl S��i'Y3CP,ly 11 'ZVI.�Al�fi
+, +.
Date Signature of Contractor'��`^ ����}''"'� ft j
f:
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 ownei 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'ceetificate 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:
Cartier Policy No.
0OLDEN FA10LIV INS NW
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) .1 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. 1,
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
fora 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.
Signature (Owner/Agent)rr� J0i, a '�*�'f (` Date- i J
s _ti w
BUILDAG PERMIT PERMIT#
DATE VALUATION LOT TRACT
24197.2.
JOB SITE 9 4APN
ADDRESS
OWNER
CONTRACTOR/ / EN INEER
4J.(✓3• .J. Y.DESIGNER
w
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i.+rr�`T C1R/A bli.OWM11, 04.I,CV1[¢LI7.IUMN9
1535 Q`50, ID" 8 Mirf°3, T311K. O W,)
1533 S.0. ".�" UIRIET, STEL #2.00
5f14 1:3' ,lt,NR D:f ,10 CA 9240
a3A21 WMN,PsR.,t':INO t",A 92.406
(909) 816-6007 Mull; 2120
USE OF PERMIT
SMN PLAN 35)'Z,sra ,LDT 9 ". 21A?.MIT DOM NOT IN 1AJDF;.131,CArCX
�.�.�:�.���1;� �:§.��ii, Cir�.�.ii.�s,�!:�'9h3���3.��� ,i �-J �tl' T :1' ��(� �'+':..'.i"r� %� �_ .. ..%L-*-• "
.�rf.r° tl: `�.< N . Y.1 4.�•s� ..'.e t ..l! r a/t .r3 >- +f F , .ry a :N• .rj 'r r ...�+'
T RACI, C" NST 1iiT T1014 71215.00 r;;;:
PokC:ivlw to 20,00 SF
C1�,!3C�iA;ARf)pt`' 6".09 iii
.1d1ltKD tDS' C5=,LVf>(RIUC',rlo..I
3'mat{1a'0 -
t1 7. °�'li►:.t'i'i 2�'19 101-000-418-000
. ).t et10
PLA.M 101-000439-319 y
NIRC'i~WTtCAL7 9 .101.¢000~121-000 U0,00
.9�t ,Ft;y�TRIC�.�,6��>,svFEE 1.,th�yl-A000-�n.20-0>00
lIFaI-U f53
T.Ziaii.MB114, q,T. Y iii, 10 S -000-4 f. ✓"04x0 S12A.00
,", 7 OT40 l OT.'ION Yit,f; • f41i1 D 101. -000-241-00 $13.20
MADWO ?Kt 101-000-423-00D $20,00
YDWEL01"Elf. IMPACT PR �i,9i17.00
ANT) 01 RICK.
$3,177.93
LOOS AUG -3
'01N OF 01 Qt'!NTA
RECEIPT
DATE -
BY }
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backsf�
Forms Footings _ /
Slab Grade
Steel /
Roof Deck /3�b1
O.K. to Wrap
SSC
•i
�
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U..
Framing
Insulation
L
.� D�
(Y _
Compressor
Vents
Ajl—
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath ZZ 2- —e" -
Drywall - Int. Lath
Final
Final
3 — /� 2,
wg'S
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
Water Piping C�
Heater Final
Plumbing Final
Plumbing Top Out
Shower Pans
/
��� %
Equipment Enclosure
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
L _
Gas Test
/ - q -- 2 -
Appliances
Final
COMMENTS:
13/3
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 3-
Utility Notice (Perm) Z
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INSULATION CERTIFICATE,
•
This is to.certify that insulation has been installed in conformance with the current energy
,
California Administrative Code, Title 24, State of California, inthe building located at..
N
regulation,
79-899 William Stone Way, Lot 8, Monticello -Heritage, La Qulnta, CaliforniaCEILING-
.
- TYP OW MANUFACTURER: CERTAINTEED. THICKNESS: R-38
'
-
TYPE: BAtTS MANUFACTURER: CERTAINTEED THICKNESS: R-13
GENE CONT TLC CENTURY CROWELL COMMUNITIES LICENSE # 71y1
TITLE:
;.
BY:
PARAGON SCHMID BUILDING PRODUCTS, A MASCO COMPANY LJCENSE # 532072
B TITLE: ADMINISTRATIVE ASSISTANT DATE: 12/12/2002
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