0108-023 (SFD)'* LICENSED CONTRACTOR DECLARATION f
CI) I hereby affirm under penalty of perjury that I am licensed under provisions of
"I- Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
04 W Professionals Code, and my License is in full force and effect.
C :3 th License# Lic. Class Exp. Date
UJI � r_ '11:4) tits. 13 s� i
Z r- Date ' Signature of Contractor
tD 0- ,
f~ OWNER -BUILDER DECLARATION
aCD
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
17) License Law for the following reason:
Z_ ( ) 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).
( ) I, as owner, of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
Cf) () I am exempt under Section , B&P.C., for this reason
O LID
Date Signature of Owner
rn
n. Q WORKER'S COMPENSATION DECLARATION
-
p Z I hereby, affirm under, penalty of perjury one of the following declarations:
;r H Cl
O O 1 have and will maintain a,certificate of consent; to self-insurefor workers'
X LI [: compensation, as provided for by Section 3700 of the Labor Code, for the
mJ Q performance of the work for which this permit is issued.
Q U ( ) 1 have -and will maintain workers' compensation insurance, as required.by
Q V• Q Section 3700 of the Labor Code, for the performance of the work for which this
d � Z permit is issued. My workers' compensation insurance carrier & policy no. are:
r Q Carver Cft,71�x�XH 9�h.(}1�+.IN8 Policy No. NWC444068.03
J (This -section need not) be completed ff. the permit valuation is for $100.00 or less).
O 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 wlth'those provisions.
Date ' Applicant �'"-
Warning Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penaities: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.
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) f_> .�— Date
BUILDING PERMIT PERMIT#
DATE t VALUATION LOT �D�(2 TRACT
j
14197-2
JOB SITE
APN
ADDRESS
19-94.5 i3ANCOCK, CO1tTR`3.'
M1r4_0112-t1XKr
OWNER
r'
CONTRACTOR (DESIGNER / ENGINEER j
ClCi.W17, Yp•��La�3�Wry�:i�.L Cilr�itr�/�J�:���'�.LIES
yy�C��p�/Y��ji1�y{.��i+y;G �:C�Dy���t�t�lurr..
54,15 S01 1)" 4MET, MT 0200
�'�s/A!'TI./1
1535' to, R.f�'- IJ�Lh'�.L:r� , /i, vino
SAN "BM-1A.1i`1:1N0 CA 92408
SAN J9KkN.A_R i1' 0 CA 97A OO
(909)3SI-6007 CITL k 2120
USE OF PERMIT
:1€�1:D• #�1.�t1� dB,;1�G1'1`14• T'Wtti(btlT llf7�S AI!+O'i' lA1CL.t1UE �?iIL,ILlC;�
Wr'1.k 1.,V4P(XA.4 3PA SJR DRIVE:WAYA&PROA H l.Si% H.,AN CHECK PRE
REL"�'UCT)CtN 1VOR 1S3UJt. 4C9.UF aMAF PLAN TY''PIF
TRACT Cs>NSMUC'°t 1014 2,40A00 OF
PORCHtP. TIC s'p
(MiiACd0::.ARI ORT :,.. tifi4,dt1 SF
X1FJ3 r C(Wr OF CoNsygucuoN
1412 #O)
iPERMFdf' .Flak SUMMARY
t; t)Nff7'MICT;0H FEE 301-000-41184)(10 $79010
PIAN CHWK FrA 101 -OW -439-328 '$163.38
MM" HANICAL ME 101.000-4214M 56640
ELXC'1 RJC.A.L 1E,Cs 1011 -000 -420 -OW $144"43
1PL[ll`![i31 O FER 101.000419.000 214',Ob
STltGHO MOTION FU - RESID 101-000-241-000 $14.30
Offi,AlA INO iGr.FE 101-000-423,000 $20.00
1:D11yVL1.0PKR IMPACT ME
13 i ` .L t"C?X� x�AM) ;PLM HM
83,2A9.€6
LEM PRE-i'r'U :i M,
`x0,00 E
I (f
WKrf FIT.9 DUE .NOW
: AUG 3
- 2001TV.r
s -
C 1`i iii I fC C�i�+IA I
I•i4l��i Ili:Gl : '
RECEIPT
DATE
BY f
1• J
DA 'FINAL D• ., /
�/ �v
INSPECTOR
s
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
WLEIING
APPROVALS.
HECHWCAL APPROVALS
Set Backs
Forms & Footings
J
L
Underground Ducts
Ducts
Slab Grade
Return Air
Steel
Combustion 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
Ekterior Lath
r $ OJ
Drywall - Int. Lath
Final
Final o—Zi
BLOCKWALLL. APPROVALS
POOLS e SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to.Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMB NG APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
ShowerPans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Bearer Connection
Encapsulation
Gas Piping
Gas Test
.57
Appliances
Final
Final
Utility Notice (Gas) v �.
ELCCiP=AL 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
Utility Notice (Perm) •—
COMMENTS:
1{4,(17-/ E019
/.riaY,+it�Y/rNinV..�I/i%>'NIW,W/�o/AAw'raI'N/Ns'JNNNJY+//�+1rfIM'/F'/Nr41A'JYSN4'/YwrriXN/YWfnNY.IY/I/A%6VYIIYYi49/1Y.7IN.'VllM6f./l�J.WIYIA/Y�YI.IiJi/AIM'/.:AI/1N19I4'M/1'!/NJI.n:�
INSULATION CERTIFICATE
This is to certify that insulation has been Installed1n conformance with the current energy
regulation, California Administrative Code, Tide 24, Stale of California, in the building looted at;
t
79.943 Hancock Court, Lot 19, Monticello -Heritage, La Qulnte, California
CEILI
TYPE: BLOW MANUFACTURER: Certaintead Thiokness:, R-38'
WALLS:
TYPE: BATTS MANUFACTURER: Certaintead Thickness: R-`13
GENERAL C NTRACTOR: CENTURY CROWELL COMMUNITITES ,LICENSE #
BY: TITLE: 149" -6uu'
PARAGON SCHMID BUILDING PRODUCTS, A MASCO'COMPANY LICENSE # 632072
TITLE: ADMINISTRATIVE ASSISTANT DATE: 1211'212002'
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