0108-028 (SFD)CO
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�. 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
x'.31 1 101:11,rCiI
Date - rte—' ' / Signature of ContractorY {`l''� `� %� ��•�
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 & Profesionals 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. forthis 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 Policy No.
001,DKH R&OLE INS. 1+ WC•5A4060•03
(This•section need not be completed1 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. 1 should. become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions:- ,
Date: / r 1 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 (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. i
Signature (Owner/Agent] > >+ , / �r +` '?� Date �
BUILDING PERMIT PERMIT#
DATE t VALUATION LOT 01i113-fa8 TRACT
i S116,428.10 24 241SrIj
JOB SITE
APN
ADDRESS lrbA.UGG1C S, r())3Tt7'
-(Kk
OWNER
CONTRACTOR/DESIGNER/ENGINEER
am. 0.209
3 535 SCS. T11-WrIPI1Er, WL , .9200
SA141•iERNARDINO CA 9 408
SAW 13M4AR DING CA 92408
(909Y,4111: �f 907 CBLO 2120
USE OF PERMIT
&k3ULF,1%r�i1ro?13'
Stl?Y')- PIAN i ARev, LAY' 24.1`'F.1'i M1'i'DOES NOT INCLUOP S'i,ACK
'il A1,I..S1F j011,, SOPA 01,R DRIV7WAY APPROACH
TiiACT CO1+RRUCTION ,-4,01100 S
PORCH(P:ATIO 35.40 3i+'
QARAQWA;;PORT 640,0 SY
F.51THMAM COST 01i. COTT Int'. CnO. - '
V6.428.20
1~' E` wA:.Me mllw?y
001148 'RUCTIOW 1E1'.? 101 -OW4 18.0LYJ $999,00
PIX AW CHWK FM 101-000-439-318 $7*1.68
MKkl.A7. "CAL li k 101.000-A-23.000 $7%00
if LECTRIC.Al. ii'1W 101 -WO -42"00 $aaa n
FL';tMBING FEE 101.OW-4149.000 21161.: $
3TR.CYNO 919i)7'ION FX► RnID 1101-000-241-000 $17.64
(3Nt1D1)+!0 KT 101-000-41,13-000 $20A
LlEVEIsCWER.IMPACT FEE $1,907.00
'L UCT.1 ..9 Alff) Pi..t0.+1 CIWAt .K
$4,01129
s
LIMB PRA -PAM ice::
$e3,00
AUG — 3 2001 1<I?j�Jt14I I;Ii:�D�a�vdy1':�
i CiYY i)F LA L11,KA
FINA,KE DEPT f
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
1
USPECTM RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BWLDING
APPROVALS
MECHAHCAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
�Q f _
Return Aire
/
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
p
��/
Compressor
Insulation
�%
Vents
Fireplace P.L.
_
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
_
-.29 Z �
POOLS - SPAS
BL OCKWALL
APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
- /3-02
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMB�NG APPROVALS
Gas Test
Waste Lines
`Z �V� (� C
Electric Final
Heater Final
Water Piping
/ _
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Piaster
Sewer Lateral
Pool Cover
Sewer Connection
/ _ /,22 -cie
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
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
0 — - Z
Utility Notice (Perm)
2-/y-
3
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INCL LION CERTIFICATE
This, 18 40, 08dify1hat insulation ihas bean installed in conformratice with to current energy
regulation, Caldbmia,Administmflve Code; Title 24, State cf C. elftmis, In the building located at:
79.888 Hancock,Court, Lot 24', Montioello-Heritage; La.Quinta, Catifornla
EI N :
TYPE: BLOW MANUFACTURER: CERTAINTEED THICK NEBB: 11.38
TYPE
WALLS:
MANUFACTURER,. CERTAINTEED THICKNESS: R-113,
GENERAL CONTRACTOR; CENTURY CROWELL COMMUNITIES LICENSE* 741/
BY: TITLE: de^ S42Aei
PARAGON SCHMID BUILDING PRODUCTS, A MASCO COMPANY LICENSE # 832072
Qy: TITLE" ADMINISTRATIVE ASSISTANT DATE:12l12/2DD2