0005-316 (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
r
Signature of Contractoor
YtiI
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).'
( ) I, as owner 'of the property, am exclusively contracting with licensed
contractors to construct' the project, (Sec. 7044, Busine$$ & Prnfacv.ionalo
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:
Carrier GOLDEN KAOLE INS, Policy No. NWC-.944068-02
(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 pr visions of Sbction 3700 of the Labor
Code I s�ja11.4ortwit comply with�tho a p'rovisi'ons"
Datef Applicant `'-
Warning: Falure 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
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 propertyforfor inspection purs. f��
�
Signature (Owner/Agent)'Y Dates ti _ /
BUILDING PERMIT PERMIO
4iidS-;Ali
DATE "T VALUATION LOT 23 TRACT
JOB SITE -
APN '
ADDRESS f ,mim wAy
OWNER
CONTRACTOR/DESIGNER/EN (NEER
cEw"l'f 1 .y tptow I:'L ct7mmJ1+TI'Jus
CD3'I'L'IRY CROWML !C%3MM,MMS
1535:30. TPn-:T, SM 0200
1535 "MIX S'I'T EEM FO. 4200
&k*gBP ARDILJO CA 97,408
81NEERNA;RD131TO C.,A. 92409
(909)381.6001 CSVf 2120
,
USE OF PERMIT is
SFD:, PL,A14 3C IAT E3 PERMIT DOES NOT INCLUDE 13 : OCKWALL.S OR
POOL
r.
TRACE` CO-OSTRUC,T16N 2,450.00 OF
PORCHIPATIO 29,00 S?
C1E1.R AMUCsA.RPORT (U) Z%173,30
EMMMED C!0ST OF CONS"YJ:2'i7MO.N
14. oo,
PEPMr 1 FEE SUAdUARY
CONS7' UC:TION FEE 101.000-41 £3-000 $,785.511
x „
PLAN CHECK FEE 101.000-439-318 $647.1
MEC.HANICALAF-EE 10;L:-0(1044 .000 x'97.00
'
x
ELECTRICAL CTR.ICAL FEE 101-000-420-000 $127.59
PLUMBING FEE 101,?000-419-000 $13435
STRO NQ MOTION FFE - RE UD 101-000- 1-0043
C RADIAit FRE 101.000.423.000 A20.00
A =,
IDEVEWPEA INI ACT ISE';
SUB- TOTAL CON H-TRUCfTOW A,L D ;P1:" CHEM
$3,'91 A..1 S
1X33 PXE-'P, ATD ITE61
Saw
TOTAL 144. i. IMS D'l>1<.EOE
RECEIPT
DATE
BY
DATE FIN
INSPECTOR
INSPECTION RECORD
ti. OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
_�
Underground Ducts
Forms & Footings
Ducts
Slab Grade
— p
Return Air
Steel
Combustion Air
Roof Deck
/,?
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
of
Compressor
Insulation
a of
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
I ��
Drywall - Int. Lath
I r7(�
Final
Final .o _
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
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
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 p
Final o
Utility Notice (Perm)
COMMENTS:
,.4
WESTERN INSULATION, INC.
i` 4211 Latham Street, Riverside, California 92501
Tel. (909) 686-8760 Fax (909) 686-8786
,
INSULATION CERTIFICATE
THIS IS TO CERTIFY THAT INSULATION HAS BEEN INSTALLED IN CONFORMANCE WITH
THE CURRENT ENERGY REGULATION, CALIFORNIA ADMINISTRATIVE CODE, TITLE 24,
STATE OF CALIFORNIA, IN THE BUILDING LOCATED AT:.
TRACT / PHASE: STARLIGHT DUNES 23773-5
LOT # 23
SITE ADDRESS: .78-900 ZENITH WAY LA QUINTA, CA
EXTERIOR WALLS: '
+
MANUFACTURER:,' JOHNS MANVILLE THICKNESS: 3 5/8 " R -VALUE: R-13
1 " CEILINGS: BATT BLOW s
MANUFACTURER: GREENS E--- THICKNESS: 10.3 R- VALUE: R-38
CEILINGS: BATTS BLOW
MANUFACTURER: JOHNS MANVILLE THI S. 13"' R- VALUE:, R-:58
0
GENERAL CONTRACTOR: CENTURY HOMES'-,,
BY:
TITLE
DATE:.
INSULATION CONTRACTOR: WESTERN INSULATION, INC.
LICENSE NUMBER: 481278
BY:
TITLE: PRODUdf1dN M AGER y
DATE v