0112-058 (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 # Lic. Class Exp. Date
"l. X4094 A B 1XI C /3 1/0:51
Date i w, �Signature of Confeactor-"•` "'
'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 C•,)de).
(- :) 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 perniit;is issued.
Se( � I have and will maintain workers' compensation insurance, as required by
tion 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 ZURIC^H AMRR All Po"cy.No. W%ff.12200-03
(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 provisiogqS.
,"Date: t 1 f S- j -i 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., theconditions and. restrictions set forth on/ffils�
application.
1. Each person upon whose behalf this application is made & each person at
r
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 employeesM
2. Any permit issued as a result of Elis application becomes null and void��.I,f
work is not commenced within 180 days from date of issuance of sP .
permit, or cessation of work for 180 days will subject permit to cancellat on:
I certify that I have read this application and state that the above informatio Is
correct. I agree to comply with all City, and State laws relating to the buil rng ,,;
construction, and hereby authorize representatives of this City to enter upon)'
the above-mentioned property for inspection purposes.
J r,�
Si nature Owner/Agent fes" ` 1'•� Date '°
l
- BUILDING PERMIT PERMIT #01,
'
t' 5 °-4-
DATE VALUATION LOTS TRACT
21
JOB SITE,/.....
ADDRESS 2
7'7 I ait if�} _
�f69'E) `5 il�l2
OWNER
CONTRACTOR/DESIGNER/EN (NEER
CEWEX 1,10)al! - W -AND DSVIMc
N 0,WM7, Ha &
.2280 WAPY)LO W r—MCY I MM. 150
2280 WA WNV CM(,T;r!, 9t1:A' ? 1.50
i" kONA C.A. 91720
CORONA (-'.A. 91720
.909; b9,,400-0 C. L � .s�c'1
USE OF PERMIT
V0 ,: JA) ' 2 PLAN 3 C I, PMUT DfJ&S, NOT INCIX11% BLOCK WAIA a,
P00USPA OR DR.1V WAY APPROACH. 7.5% RZDUCT104 TO PIAN CHECK
nE YCrR MULTIPLF, ISSUANCE OF S"IE VL. q `tYf".i?
CUSTOM C:O'Rd TRUC`PION IiMV10 SP
P01tCeifl'"A'aO 535.00 SF
0A R.NMIC kPIPORT 448.00 SP
COO* OF CONS. i7C"�°1ON
271l,7:97M
x�9, ay,•�,�yi�p. T�a�t9•;t C�y'y �,g��p-� y1M6YM`kfi�kli1',f"
. ,Ti".tl4 .IlW, ff 7f1 dt E 67iA.Li'+7.GlAkM
C011811AVICTION PE)~, 101.000°418-000 $1,241.30
X'1,.AN t;kt[�,. K FX19 101 -WO -439-318 $252.35
M>.?,C'fWN,1ICAL FRI,, 101.000.4:21.000 5113140
XLW,TR1.CA,L, FMV, 101-0.00-420-000' $176.44
PLE9A1(I3ING FEE 101-000.419-(-013 $192,50
V)ICING MOTION F2r? - RP .VD 101-000-2A I -000 $27..19
ci',ADWO FEE 101-000-423-00n $220.00
T83AU-1S9'k'UC1'J! i3R 225-000-44:3-349,, $1,90.00
MT IN PTIDLIC' PT ACE. - R.89K 270 -GOO -445-000 -000 9179.40
__. 913C..OI MUM MDk�g.ef.��3 MRIC,�'..
`.
$4,1'14.46
•
� p� 'p YAtJ r�, yv q.•�trt+ OVA!
�1.;Ronny
VY
DEC 1 TO�.E.iJ, d Mw R'Y.Tn�hh/' ;-+VA! NOW
5bd��.n 8r'9iJ
3 2001•.:..
RECEIPT
DATE 1
BY��y
DATE IN
INS COR
INSPECTION RECORD
OPERATION DATE INSPECTOR
BUILDING: APPROVALS
Set Backs
Forms & Footings(
Slab Grade 44-
Steel
LSteel
Roof Deck _�S 0 L-
O.K. to Wrap
Framing -� I
Insulation
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Party Wall Firewall
Exterior Lath VIV.-
Drvwall - Int. Lath
Final
BLOCKWALL/APPROV,
Set Backs
Footings
Bond Beam
PLUMBING
APPROVALS
Waste Lines
MECHANICAL APPROVALS
Water Piping
Plumbing Top Out
_
-a� 4Z)
-�
Shower Pans
Sewer Lateral
Sewer Connection
Compressor
Gas Piping
Gas Test
_
OPERATION
DATE
INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
_
-a� 4Z)
-�
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans & Controls
Condensate Lines
Final
Steel
Electric Bond
Main Drain
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Gas Piping
Gas Test
Electric Final
Heater Final
Plumbing Final
Equipment Enclosure
O.K. for Finish Plaster
Pool Cover
POOLS SPAS
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL _APPROVALS
Temp. Power Pole
Underaround Conduit I I..
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temo. Use of Power
Final
Utility Notice
06/29/20,131 21: 32 FA:Y 12160 6
INSULATION CERTIFICATE
This Ls to certify that insulation has been installed in conformance with the current energy
regulation, California Administrative Code, Title 24, State of California, in the ou=lding at
56=277-Winged,F0ot, Lot_2,_La Ouinta; California -
CEILINGS:
TYPE: BLOW MANUFAC'T'URER: Certainteed THICKNESS. R-38
WALLS:
TYPE: BATTS MANUFACTURER: Certainteed THICKtvIrS-.z,:" R-13
GENERAL CONTRACTOR: CENTEX HOMES LICENSE#t:'
BY: TITLE;
PARAGON:3CHMID BUILDING PRODUCTS, a MASCO Company LICENSE #221517
BY,
"—"" - TITLE: ADi141NISTRATIVE ASSISTANT CATS; 8113/2
f
INS_ ULA110IN CERTIFICATE
This is to certify that insulation has beE:n Installed in conformance with the current energy
regulation, Califomia Administrative Code, Title 24., Stdte of California, in the building located at _
56-259 Winged Foot, Lot 1, La I3uinta, California
CEILINGS:
TYPE,- BLOW . MANUFACTURER: Certainteed THICK14ESS: R-38
WALLS:
TYPE:"BATTS MANUFACTURER: Certainteed THI0i--<NESS: R-13
GENERAL, CONTRACTOR:. CENTEX HOMES
LICENSE ;#
BY: TITLE:
PARAGON >CHMID BUILDING PRODUCTS, a MASCO Company LICENSE #221517
BY: T�,..lTr-
TITLE—ADMINISTRATIVE .ASSISTANT UAf =: 8/13/02