0011-127 (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
748004 A V ;1 Date r� f ��° Signature of Contractor+
J A
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, Business & Professionals
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.
(�(�r I have and will maintain workers' compensation insurance, as required by
Serotion 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.
STATE COI14.P&HOATI 'I'd3L►WC
(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 pfo /igions.
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 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 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 property4or inspection purposes.
Signature (Owner/Agent) rI /,,� '' S `j Date')I �E•�f
BUILDING PERMIT PERMIT#
DATE VALUATION LOT WORM -2-1, TRACT
//yy dd�ry }}''�� 4 99�T}� ��••���g����'� (�finr ((�� II�� ��((��p
1111 9f.CRJ\r 'V200r7tAL�.90 �.7--! .2)3W3-1
JOB SITE
APN
ADDRESS r.J.-,..-,r�_�,r--
. A �.�.i�O.
-761-GW.-078
OWNER
CONTRACTOR / DESIGNER / ENGINEER
1:61 INDMA AVL
'7161 DW1X4A.} VF_
RIVERWE C.I. 92504
FtlVEIt1913L`E OA,. 9.2304
(909)784^0840 CM.0 5357
USE OF PERMIT
5100 - IDT 39, PIAN 20, PPRR91'T "DOES NOT T INCLI SIZ. BLOCK WALL, OP,
k'47LJL 1316PLANCidECK Fft 014 MULTIPLE I8SUAI CE. OF SAME PLAN
TYPE
CiLILTOM CONSTRUCTION 2,3W,00 SF
PORCFtfP ATIO Z3Sv.G4i SY
S-ARAt' WC,ARPORT 03T) 1-2,4.46:00
%�a1 i!Rt�TI m COST OF C:3;I;e'�MC'CTION
2001909.9. 0
14W,411799 673MMARY
CaN101 f`RLICTION FPIX 101-000-4,18-000 WIN
PLAN CHECK FE l01-tbfJlo3-•�' 3� �'I b $J4�?, �9
,
ME0W11C.A.11111.SL 1iil�Ol30•�BZGv(1t3" $ ,50
-y ' 3
RlX,C--a`RtG,AL FU t.01-000420-000 $148.47-
1nxf nwqT,mo PER 101-000.419.000 RiHAD
ST€tiE'I` a ApDTION RE -1 I"D 101-000-241.OW.
f3i�:~tL"1i�0 I? IO] •Ot' �i'+aa"C1Lii3 �2f?,W0
""' ? r
DFVF.t,t'$PXR. 7ibS,FP5C7' Iplt: $D,4!P�'.0lt
w. r
AIT Ili P11811C.PL.ACES -R no IE 701.000.253.000
i3-11WAL, C 1^+WS'1C:£ttlaflow kND PLAX (W -110K
LW3 PIW-PAID HIM
$0100
TOTAL PYM911 Ffms DUE NOW
RECEIPT
DATEBY
If" 1.
DAT FINALED
0_03
INSPECTOR
�
"'A ,#`r�
-03
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Roof Deck
sl( al GIN
Combustion Air
Exhaust Fans
0. K. to Wrap
Framing 07e,?b�.c_,S_�L
Insulation
_
9/��/
F.A.U.
Compressor
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior lath
Drywall -Int. Lath
Drywall
-
7777%
_
Final pj` 03�
BLOCKWALL APPROVALS
Final
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg, Test
Final
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
Sewer Connection
Gas Piping
Gas Test
Appliances
�l ���
Pool Cover
Encapsulation
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
Utility Notice (Perm)
08/07/2003 07:43 9096868786 WESTERN INSULATION PAGE 03/03
1
WESTERN INSULATION, L.P.
421.1. Latham Street, 12ivrrgide, California 92501
Tel. (909) 686-8760 Fax (909) 686-8786
CFf R 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: HERMITAGE / PHASE 4
LOT #: 39 _ _ _
SITE ADDRESS: t80-968,HERMITAGE, LA'QUINTA, CA
EXTERIOR WALLS: BATTS
MANUFACTURER: KNAUF THICKNESS: 3 1/2" R- VALUE: R-15
CEILINGS:
MANUFACTURER: GREENFIBER
CEILINGS PLAN 2 ONLY)-
MANUFACTURER:
NLY :MANUFACTURER: JOHNS MANVILLE
CEILINGS:
MANUFACTURER: GREENFIBER
CEILINGS:
MANUFACTURER: JOHNS MANVILLE
BLOWN INSULATION
THICKNESS: 10.3" R- VALUE: R-38
BATTS
THICKNESS: 13" R- VALUE: R-38
BLOWN INSULATION
THICKNESS: 5.1" R- VALUE: R-19
BATTS
THICKNESS: 6 3/4" R- VALUE: R-19
GENERAL CONTRACTOR: STEVEN WALKER
BY:
TITLE:'
DATE:
INSULATION CONTRACTOR: WESTERN INSULATION, L.P,
LICENSE NU R: 79
BY: —L If // j
TITLE: PRO T ON MANAGER
DATE: AU UST 7, 2003