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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
1418$ H a 1.0/31101.
Date '' f " ° Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1, 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).
( ) 1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
O I am exempt under$ection 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:
O 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.
(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: ~�'..� .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 Qujnta, 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/Agehi) r r /=�'' �" �" { Date
ii
BUILDING -PERMIT PERMIT#
DATE VALUATION LOT 01084*04 TRACT
20 24.197-2
JOB SITE
APN
ADDRESS
7 I FIANU.''1C"K C'OlatvT
604-0'rl-Or
OWNER
CONTRACTOR / DESIGNER / EN (NEER
CIFINTUTAliY (11t aWB4...iM!:°QMMU1FffFZ
c..E 41TURYi C.°Ii.Ov, ..,3:, 001c w0.wri--S
1535 U13 OF)" STRF'T, Sm'Rn00
1 735 SO, 9)4;5T1 'Q4',Z UTE 02W
SAN 1:0"ARD:t1dO CIA 9V,08
&49,'8FJMARDW .3 Ch 92409
(9.09pol-600 CIB14 2120
USE OF PERMIT
3C3 3WA.34. Ly r Z1;ftJ
SM PIAN 31Attev, LOT20 - PUMIT OIDS.5'NCIT I3dC:LVOE UL0C:IK
WAI.1.K'tfPOOLr, SPA OR 1)R3i1'ia;Wje it APl''ItColtCH °P'IX Pl,4N CHECK F,B
1€E DUC FIGN FOR ISSUA14CZ W Xt AR, PIAN TYPE
TRACT CONSTRUCTION 2,215,00 SF
FORC'.HIPATIO 29.00 str
t' IARAC1RKIAkY'ORT 6.25. k4 SF
1iN1'f NXM) Cf:'+ff OF C 01*4 1Tt'8,TCn0N
:I IK TFk" sTfAqti ZY
iC0?'lrlTf UC111014 IRE 101-000-416-000 V66.0
PLA14 iCHW- K WIN, 101-000.4.'49-31I3 $160.11
1!-C'1�.�r*,1;iiWI FEE 101 -OM -421 -OW 42:1 -OW Sol"
PL,UiJllti'11'd01 EE, 101.000.419.000 $124.00
3l''I2ONO140TION WI -000-24.1-000 $13.29
(311 ADfl+ O PER $20,00
Y3WEIA)PEP I.MPAC:T YZE $1,907.00
9U�1�'t�l9?'1'm C'' JC, .t.& A14i31 LAN OWIKK
L= PlZ -PAW MIS
$3,177.93
$0,00
`
AUG — 3 2001 :a k X LET M. �� cavv
0,177 93
CIt`i N U� 0.1,0Vd
FINrrI)FI
_ .�
RECEIPT
DATE
BY '
DATE FINALED
INSPECTOR
INSFE;�TIC�N RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BULDWG
APPROVALS
NECHANN CAL APPROVALS
Set Backs
_ _
Underground Ducts
Forms & Footings
% !
Ducts
_
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
_
`/ p( _
F.A.U.
Framing
Compressor
Insulation
_p
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final'
— Z
Final
3- 17- S
POOLS - SPAS
OLOCKWAlLL APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMSWG APPROVALS
Gas Test
Waste Lines
(%T p� C
Electric Final
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
COMMENTS:
Final
Utility Notice (Gas)
ELECTRG CAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterioi Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Ficial
Utility Notice (Perm)
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INSULATION ACERTIFICATE
This is to certify theflnsulation has been Installed in conformance with ft cutrent energy
regulation, California Adminietrathe Codd, Titre 240 State of California, In the building boated at
79.831 Hancock Court, Lot,20, Monticello -Heritage, La Quints, California
CEILINGS:
TYPE: BLOW MANUFACTURER: CERTAINTEED THICKNESS: R48
TTS MANUFACTURER. CERTAINTEED THICKNESS: 11-13
GENERAL CONTRACTOR* CENTURY CROWELL GO/6w
MMUITI
NES LICENSE #
BY: TITM 1; i
PARAGON SCHMID BUILDING PRODUCTS, A MASCO COMPANY LICENSE # 682072
g TITLEt ADMiNiSTRAT'INE ASSISTANT DATE: 1711212002