0108-010 (SFD)LICENSED CONTRACTOR DECLARATION `
`i hereby affirm under penalty of perjury that I am licensed under provisions of
0' apter 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 c•rl`' ,�``r Signature of Contractorff v r� ��/ �fr '
v.., v.
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
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.
001ARN '9AM.8 IMI "C44400 -tai
(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: Y`,L4 �` 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. f
Signature (Owner/Agent) t ? f •4 Date. ' 1�y
BUILDING PERMIT - PERMIT #
DATE) i VALUATION LOT TRACT
JOB SITE !
APN
ADDRESS '
87MCK
WA -07"06
OWNER
CONTRACTOR / DESIGNER / ENGINEER
C•S�OVV,> ILL CC7SvMCWDES
1CF-kr'Mply MU' "J KI, C:OMWIM111ma
CA. 92408
MCBMW ARDR43 CA. 92408
(909)581-6007 t''mg 21'Z0
USE OF PERMIT
i
:%I`';:9. FPI..AN 313Rt.ev, LOT& PM',VVJT DOES 1303' T'NC.LUT)V DLOe;tC
W JAR -00TH SPA. OR fiT13+1'F.WAYAPP}iL"tACH 7,,T1-7,-
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3"ki..A1.E';'i Ct,NVYRUCTION 4213.00 3?
PORC,•.�����;�<;�.29.00 SF
0ARA,�gTIQ Orte aF
C010T'1t.UC JON PRE 101.000,418.000
FI..AN e,HFCK FrF, 101-000439-318 $160.11
r�r;CHANIC.AL YU, 101-000-01-000 300.001
Ii1rX 101-000-4.20-000 *13R.33
T39.UMBIHO Fisk? 101.000.419-VOU 2021.00
;3'l'RONG MOTION - M14SID 101-t?00-241-000 $13.29
f,lRAS)!NGFEW E01.400-423-000 $20.0
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I 1, �I # ^_•�. ,.V,_ 4 L&13 PR PAID EMS
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rECEIPT,
DATE BY /
DATE FINALED
INSPECTOR
1
F^
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms &Footings
_
v 0
Underground Ducts
Ducts
Slab Grade2167
V064?C
Return Air
Steel _
Roof Deck�6� 6
O.K. to Wrap %(J 2 0_/ .�4/.e
Framing 77T- x(
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Insulation
/ U (
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
_
Drywall - Int. Lath
=.27_O/
-
Final
%�'% Z'S
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
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Water Piping
_
� ��C
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
Appliances
Final
COMMENTS:
'
Final 3
Utility Notice (Gas) �T—
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final _ L
Utility Notice (Perm) �=.
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INSULATION CERTIFICATE
r
This is to certify that insulation has been installed in conformance with the current energy
f regulation, California,Administrative Code, Title 24, State of California, in the building located at:
79.927 William Stone Way, Lot 5, Monticello -Heritage, La QuInta, Catliomla
CEILINGS:-.:.
TYPE: BLOW MANUFACTURER: CERTAINTEED THICKNESS: R-38
TYPE: BATTS MANUFACTURER: CERTAINTEED THICKNESS: R-13
GENER,4 CON CTOR: CENTURY CROWELL COMMUNITIES LICENSE #
BY: CGL TITLE:
f PARAGON SCHMID BUILDING PRODUCTS, A MASCO COMPANY LICENSE # 632072
BY: TITLE: ADMINISTRATIVE ASSISTANT GATE: 12/12/2002
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