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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
76 sus n CaRIC, f� 9P304e3
Date � Signature of Contractor `'.�A '<
OWNER -BUILDER DEC4�RATION
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.
k) 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 STATE F"D Policy No. 103616f 021
(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 provisibns.
Date: � �t -•�9 Applicant"-^ t �°�' 11d, 20e,
Warning: Failure to secure Work' Compensation coverage is unlawful and
ilf
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 property for Inspection purposes.
Signature (Owner/Agent) Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT (YLTRACT
:5,3200, � � //5 29601
JOB SITE APN
ADDRESS 79.8134 DEa'KEff, WMLOW STM"T 649-030.0-15
OWNER CONTRACTOR / DESIGNER / ENGINEER
VM Ai.."LOI T.,S, LP D(S) DEV., INC dba. DE MT tom'. T&H DFV.
74.760 W..GHWAY.1 I i iWO 118-15001I[ir W.44 Y 1 I 1
WDIAN WtLS Cis. 92210 LAQL1IP1"1A t..A 92253
(760)771-3345 •tM41 2180
USE OF PERMIT
SINGLE F1!Ar1 LY ./til rAC
SPA" 1-111,111-0. M; UNIT 111% PLAN IA. 'PEt2TAI T DOFF NOT INC:1,UTZ
110. 014 SPA, DWICKWALM OR DFtl'i P*WAYAPPR.OACH. '1`5%REDUC- IO14
IN PLAt•1 CHE•Cf'n FRE FOR MtJLT1P1;.ISSUANCE OFGAIMP ta"a.&N TYPE
TRACT CONSTRUCTION ?00.00 V
C.i.AE'.ACfLPlCAlrWORY . X03.00 SP
EUMAM
COST rM t>:i)INTSMUC.tION
PYRWr YET SUMMARY
MII€sRUCTION FRE
100-000-418.000
S 81els0
PLAN CHXCK FM
101-000-439-318
$87.35
MUCH.AWMAL FEE
101-000-421-000
$39,30
P'LEC TRICA.L .
101-000-120-0010
$69.46
PLtTMCl` 03x1?
101 -000-419-000
1189.50
STRO11 O M07ION FU - R.FSID
101.000-241X000
$4.33
DMA101<91ti IMPACT FEZ
$1„imoo
M1r
i
t 8'M -TO =AL. I�1'�a°TRX1'CKTTON AND PLAN +:: ECY '$2.,2,43.34
LUS PRY-41AID-10, if; $0.00
SAY 6 ZU01 r. P. rMRS XTE NOW 920,43:R44
CITY OF LAQUINTA
FINANCEDEPT.
RECEIPT DATE BY DATE FINALED INSPECTOR
�' • to �/` � - l�t.a ,53.01
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
-Z -
Underground Ducts
Forms & Footings
—ag
Ducts
Slab Grade
Return Air
Steel
_
Combustion Air
Roof Deck
-o -?•a 37
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
_
Compressor
Insulation
-d L
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
(-ys- •oz 577
Drywall - Int. Lath
Z -%
Final
_
Final ,� 3 - / ?
BLOCKWALL APPROVALS
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 /E'
—�—� _
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
r
Pool Cover
Encapsulation
Gas Piping
Gas Test
_
- / 37-0
Appliances
Final
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) .c7
COMMENTS:
INSULATION CERTIFICATE IC -1
Si;c Address
Nrrnl: Number
Description Of Installation
1. ROOF
Jrr
Ti;: : Rcsis:�nce (R Va!uc)V,3
CEILING t r
Bat: or Blanket T,;rc E -a �'_-c�L1\�
Thickr.css (irc' -s' l3 " Tr e ^ _. ^sis:ar.c (R aloe)
Looe Fill Type OQ�t'l {��l
Contractor's rni- installed wei3hi/f:' A- Ib �4ini^_ -� t:zic'..n_ss ld-� inches
'Manufacturces it -stalled weight per square foot to ach:vvc T c:mal Resistance (R -Vale) —
3. EXTERIOR WALL
A.Ly
t�SX(o-PiC'�rt���3
Material j Bra .d Na -c a ��1Z_,-I U(1 AClt c < <0- _
Thiekress (inches) lG _ Thermal Resistance (R -Value)
13. Exterior' 'CLD
Material yP- C -&s Bn: d `a:ne LAO
Thickness (inc'r.=s) j' T e.,.,_. Resista c: (:-,,-Value)
RAISED FLOOR
V .iteri'_i
Th ic': ncss (inc`,.-s)
SLAB; FLOORi'HERIMETER
Nat�risl
Thic::ncss (inches)
Perimcter Insulaticn Doth (inches)
FOUND, -.TION NVALL
1.1;.atc. ial
Thickness (inch. -s)
Declaration
Ti:c.--31 esscar.ce (R -Value)
Banc Na -::e
T`er.;:_1 Resistance (R -Value)
Resis.anc: (R -Value)
1 hreoy ccr:ify that t: 3So%•c irsuIat,on .vas install.d in the c_:t.=.-- . _._ a`o•.c !oca: cn .,. ccr.fc iaacc with tic currLc:
fres; Ejicienc� Srer�.'r1 for residcrr.a! buildi-.&s (Title 2 :, -a- S, Ca!i.cnia Cod: o`Rcgal_^ens) as indiea�id on the
CC: iI I=ate. CFCOTr!i"n u'_... a?FC-13bI
r
lt_-i a; SLbccn':3crr (Co. Dane) OR
Gc;.c.%l Cor.-,mztor (CO. ?:ane) OR O-r,c.
F'.1_ , —
I®
"na:.:re, D3:c
Sid Da._
1-,:zlling Sub:ontmctor (Co. Mrnc) OR
Cc:icral Cor.trac:or (CO. , 'ane) OR Ow'n:r
Irs:31�Ir Subcor:_actor (Co. Narnc) OR
G...-. _! Ccr.,:l::or (Co. \3mc) OR OµTer
2-_3 A-36
Certificate of Occupancy
City of La Quinta
Building and Safety Department
This Certificate issued pursuant to the requirements of Section 109 of the Uniform Building Code,
certifying that, at the time of issuance, this structure was in compliance with the various ordinances
of the City regulating building construction or use. For the following.-
BUILDING
ollowing:
BUILDING ADDRESS: 79-804 DESERT WILLOW STREET U-1 15
Use Classification: SINGLE FAMILY ATTACHED Bldg. Permit No.: 0203-343
Occupancy Group: R-3 Type of Construction: VN Land Use Zone: CR
Owner of Building: MIRAFLORES, LP
Building Official
Address: 74-760 HIGHWAY 111 #200
City: INDIAN WELLS, CA 92210
By: STEVE TRAXEL
Date: 05-01-2003
POST IN A CONSPICUOUS PLACE