0108-031 (SFD)LICENSED CONTRACTOR DECLARATION
- •� I hereby affirm under penalty of perjury that I am licensed underprovisions.of
F_ Chapter 9 (commencing with Sectio; 7000) of Division 3 of the Business and
N LU Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
Q �
I4 +� + �1 t .y y
Q' ti F B
0 Date... '. Signature of Contractor'
J U � OWNER-BUILDERDECLARATION
HaW I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
Z_ ( } .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).
c'`) O I am exempt under Section B&RC. for this reason
I
N Date Signature of Owner
OCJ
0)
Q WORKER'S COMPENSATION DECLARATION
�p CcI hereby affirm .under penalty of perjury one of. the following declarations:
L < p O I have 'and will,maintain a certificate of consent to self -insure for workers'
XW LL compensation, as provide for by Section 3700'of the Labor Code, for the
Om J Q performance of the work for which this permit is issued.
Q L) ( ) I have,and will maintain workers' compensation insurance, as required by
Q U Q Section 3700 of the Labor Code, for the performance of the work for which this
Il 0 Z permit is issued. My workers'' compensation insurance carrier & policy no. are:
Carrier Y
cb -1 (1(?i,DEN ir.�mC 119 T"t o is o MWC4440f i -S
g (This section need not be completed if the permit valuation is for $100.00 of 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, f..
Date: c:: x%4, 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 IPO days will subject permit to cancellation.
I certify that l,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/Agent) '' ;, t ; ; ,, Date r r"
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
241 Ps -2
JOB SITE
APN
ADDRESS
79.9+$0 HANVIOCK, C0tffZr
64.072 -dam
OWNER
CONTRACTOR / DESIGNER / EN (NEER
G}?.At'rt: it otC?'mmL1'`•o1'6wmr
CEN T(JRT (7ROWKI-L COMMiL7N£CIti
15315 NU. I'D" 71REFT, MIX 07,00
1 533 SCl, eU" 9FR:FlLer, My- 420n
aAiq' is .1<7AilZ'i)T 40 QA 924M
WIRERNARDINO CA 97408
(909)381450W (''FILO 2.120
USE OF PERMIT
STD- iii iU4 4ECRey,1.07n . iyIERU611'r Dog.`; INOT IhICI.,UDZ 81XIC K
'4Y.f#UMP+ OL, OPA OR DIUVI+W,A Y APPROACH ? W� PLAN 01190' FRE
IiRD'41CTION Ib' )K )SBUANCt? OF 2tV 9 PLAN TYPE
TRACT >ti'E77NS'I'Fc>`►t,'')101J 4650.09SF
F C'i'-i+FNrit3 6100 Sir
0ARA4 EMARPORT 604;00 OF
MI&9N.f:X0 CO ►T OF C(7).fTW1RUC1x0X
1566.4f,0 J
M. F "MARY
CONS! RUCTION )fFE 101-000-41 8 -(KK) $339,00
PLAN t;:lyiECK iffy, 101-•000-44:39-31.5 $IT21.39
MICHA 11CAY, P-311 1071 ••000-42.2 •L?N
'r3'LECTRICAI,: V99 101 -000-42 -£100
I'LUMBTRO MY 101-000 -1) 9-000 $142,00
ST'E?ONO M OT1014 101-0t -00&*A I -00{10 $13.66
OR,,At'1I1NO MOP, 141-(t( 0.423.000 $20.00
E)Etlp..i s33'ER IMPACT I"£P1? $5,9117.f)Lt
`yy tll iCfFAL. 001,1:W MID PLM if'4ECr%
10,316.06
1.33 PRE1 PAID TW3
$0. (ii}
d AUG — 3 2001
1
Col Y Of LA 01,1 NTA
FINAi10E DEPT
RECEIPT DATE
BY (
DATE FINALED
INSPECTOR
'
1
INSPE�TI�N RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
WLEiN1C
APPROVALS
MECHAMCAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
�%
Ducts
Slab Grade
%,
Return Air
Steel
I rCombustion
Air
Roof Deck
Exhaust Fans-
O.K. to Wrap
_� _ _
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
/2
Drywall - Int. Lath
c y7
Final
Final
SLOCKWA
LLQ APPROVALS
Steel
Set Backs
Electric Bond
Footings
— /3 _ y Gam,
Main Drain
Bond Beam
_
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PL URfdMNG APPROVALS
Gas Test
Electric Final
Waste Lines
g72 _U{
l—
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
%=� pa
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
— 2 -
Utility
Utility Notice (Gas)
—m
ELECTMCALL 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
_ s— -
Utility Notice (Perm)
/y, p
10/17/2013 01:08 PAZ.
INSULATION CERTIFhTE
Thia is to certify that insulation has been installed In confortnanceiwlth the current energy
regulation, California Adminlstrathra Code, Tide 24, Stale of California, In the b0ding located.at:
79-940 Hancock Court, Lot 27, Monticello-Hedtaga, Le Quints, Callfamis
TYPE: BLOWMANUFACTURER: Ca taintead Thickness: R-38
.WALLS:
TYPE BATTS MANUFACTURER: Certainteed Thickness: R-13
GENERA 11 CONTRACTOR., CENTURY CROWELL COMMUNITITES LICENSE g
BY: TITLE:_ ,s
PARAGON SCHMID BUILDING, PRODUCTS, A MASCO COMPANY LICENSE #'632072
Q0116/019
TITLE: ADMINISTRATIVE ASSISTANT DATE:12/12l2002